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.
- Which software package wins urgent care? Acute or ambulatory?
- Health information exchange
- Reviewing and winning grants
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Do we put in eClinicalWorks or do we put in Allscripts? You can make arguments for both sides. The providers are going to be coming from the ED, so it should be Allscripts. But it’s going to be run by the ambulatory side of the business, and they are much more comfortable with eClinicalWorks. So it really becomes a challenge.
That’s a challenge that healthcare is really facing because insurance companies, to be frank, don’t want to pay for an ED visit. It’s much more expensive if it’s something that could be handled by an urgent care.
We have representation from community physicians and from the hospitals and somebody from public health, and we talk about some of the common issues. We talk requirement issues. We talk a lot about some of the quality health initiatives and we even about regional databases.
When you’re looking at grants, you really need to make sure you understand what it will take, because we needed to put in a lot more resources. It was so challenging for us that at one point, we actually did contemplate withdrawing from the grant.
As a CIO, sometimes you have to curb the enthusiasm. And they just say, ‘No, this is easy.’ Or I’ll hear, ‘The grant will pay for a project manager.’ Well, the grant may pay for the project manager, but in most cases you still have to find and hire someone. That itself can be a challenge.
Guerra: So one of the first things you need to understand when somebody’s talking about a change or a vendor is talking about upgrading is whether this does or does not affect the interfaces that exist to either or both of the two systems. And if it does, that’s a bigger project, and if it doesn’t, it’s a smaller project. Does that make sense?
Crowley: Correct. In fact, here’s a first example. We’re opening an urgent care center in about a month and one of the big decisions we have is, do we put in eClinicalWorks (eCW) or do we put in Allscripts? You can make arguments for both sides. The providers are going to be coming from the ED, so it should be Allscripts. But it’s going to be run by the ambulatory side of the business, and they of course are much more comfortable with eCW—all of the support staff knows eCW. So it really becomes a challenge trying to decide what system we should use. And then you can look at whether there was a different cost value and what is the IT support. But yes, you really have to give some thought to understanding what are the implications if you do one versus the other.
Guerra: You just blew my mind. I’m trying to think about that, and that’s such an interesting situation.
Crowley: And of course you have to add hospital politics in there—there’s one group that wants one side, and the other group strongly wants the other side. Who makes the decision?
Guerra: And if the vendors know about this scenario they’re each lobbying why they’re better in that area.
Crowley: Yes. And both sides can find justifications. I can find three sites out there that would tell you they’re using it for the urgent care and they’re perfectly happy; they love it. Then on the Allscripts side I can say, ‘We have somebody in the hospital whose brother-in-law brought up an urgent care center on Allscripts.’ So they think that it is the system we ought to use.
Guerra: Let me make sure I understand urgent care. Is that when you’re not sick enough to go to the emergency room, but you’re too sick to go to primary care? Is it kind of in the middle?
Crowley: Well, yes and no. The primary goal of urgent care is when you’re not sick enough to go the ED, but you either can’t get into your primary care or it’s after hours. So the other challenge that we will have with bringing up urgent care is that now, of course, it will be open on Saturdays and Sundays for 10 hours and at night. We’re still looking at what our business hours would be, but let’s say we’ll go until 9 p.m. So when you look at the support, you have to weight what your support off-hours are like—are they stronger in one than the other.
Guerra: Very interesting. I would think you need to educate the community, ‘Okay, if this is going on, go to urgent care. If this is going on, go to the emergency department.’ I don’t think I even know.
Crowley: That’s a challenge that healthcare is really facing because insurance companies, to be frank, don’t want to pay for an ED visit. It’s much more expensive if it’s something that could be handled by an urgent care. So if it is a Saturday at noon and you have a kid who you think has an earache or strep throat, the decision would be that you should take them to urgent care as compared to the ED.
Guerra: And as you said there are a number of considerations even from your IT staffing point of view that could impact the decision here—what are the hours, what are the skill sets you’ve got, and where are the majority of clinicians coming from. When are you going to make a decision that?
Crowley: Probably within the next two weeks the decision should be made, because they really do want to open it in about a month. And of course I’m trying to explain to them about all the prep work we need to do from an application stand point. And I’m looking at it from my little small world right now. I think I’m pretty good at looking things globally, but saying ‘I need to know now,’ and they’re looking at it from a larger strategic angle. But we do need to get who is ever going to be using the system trained on the system, because we’re going to bring in two new PAs to staff the urgent care and then the rest of the support will be people who are already working for us.
Guerra: You don’t have to tell me, but I know you’re rooting for one or the other.
Crowley: Actually I really will tell you that I seriously can make arguments for both sides. This is one of the cases I can make the argument that the providers, if they’re coming from our ED and it’s the head of the ED who is going to be managing the providers, then it should be on the system they’re most used to. But if all the support staff that’s going to be down there, because they’re going to share an office facility with a number of primary care clinics, know eCW really well, then maybe it should be eCW.
Guerra: And you’ll deal with whatever the decision is.
Crowley: Right. My goal is just making sure that they understand what some of the implications are. So here’s interesting implication for eCW, they license by provider. So what that means is if a PA calls out sick at 8 o’clock and they say, ‘You know what, we want to put Tommy Smith down there for the day. We’re fairly quiet in the ED, and he can just run down there and he should be able to handle it.’ We can’t do this if Tommy Smith has not been licensed to work within eCW. You normally need at least a few days if not a week to get all the paper work done to get the licensed providers into the eCW system. So that’s a small consideration. Now if you know about it and you’re well-prepared for it, you can handle that ahead of time and in a couple of different ways, but it’s still something that you need to think about when you evaluate the two systems.
Guerra: Yeah, certainly. Are there any considerations or are there any licensing models they have for someone who might need to use it according to the scenario you just described, maybe once a month?
Crowley: There is a .5 FTE so somebody can work two days a week and the cost is what’s considered .5 FTE. But to say that we could have people who work only 16 hours a month, there is not currently a plan for that.
Guerra: That’s interesting. It does present some limitations on the flexibility you just described about sending Tommy down there for the afternoon.
Guerra: Interesting. Okay, let’s talk a little bit about this HEAL 6 Grant. I’d like you to frame it from the point of view of your colleagues, educating them about money that maybe out there that they may not be thinking about or realize, and then how you went about attaining it, and what types of things they might want to think about.
Crowley: Okay. About probably five or six years ago now, New York state had a number of grants out there for the adoption of EMRs, but hospitals should always stay on top of what grants are out there, because we always go after two, three, four, or five grants a year. This was a major grant. The grant was to put in EMRs in the community to help the adoption of electronic medical records. So what we ended up going for is that we were going to develop a CHITA. Healthcare loves its acronyms, and CHITA stands for Community Health Information Technology Adoption Collaboration. What it means is we were going to get together with the community physicians and form a team that will then work together on putting in these EMRs, in the hospital and for the community physicians.
And we were going to help them because we understood from our project standpoint all of the pieces that needed to go into it—what you need to do for vendor selection, what you need for interfaces, and how do you get interfaces done. So we still have our CHITA up and running; in fact we meet once a month, even though the grant ended this July, and we have representation from community physicians and from the hospitals and somebody from public health, and we talk about some of the common issues. We talk requirement issues. We talk a lot about some of the quality health initiatives and we talk about regional databases—how do we use HIXNY and what’s the value of HIXNY.
And for a while we actually had the vendor, MedAllies, who is helping us put in the EMRs. They came to the meetings for almost a year and a half. We’ve had HIXNY come down to the meeting for a year and a half. All of our CHITA members are involved with interfacing to the regional health exchange, which we call HIXNY. So we’re sending CCDs up to HIXNY.
One of the things that was interesting for me is that the grant finished in August, and we tried to get providers come to these meetings. As I’m sure you’re well aware, it can sometimes be a challenge to get providers to come to meetings, just based on everything else they have going on. But we have a core group that comes, and we had a discussion. Do we want to continue these on a monthly basis? Do we want to maybe go to a quarterly basis? How valuable are they? Because I wasn’t sure sometimes how they really felt about it. And I was so very pleasantly surprised when they all said that they wanted to continue these on a monthly basis; that the opportunity just for them to hear something or get knowledge from one of the other participants in the meeting was worthwhile. And of course one of the two focuses we have is that we talk about meeting Meaningful Use and really measuring the quality health metrics—what’s involved, how do you document smoking cessation status, what’s the criteria for that, and what you are focusing on for your quality health initiatives. And then again we also talk about the sharing of data among each other—how best we do it and then how do we utilize our HIE.
Guerra: Do you keep an eye on healthcare IT-related grants, or do you have someone in the hospital system that brings things to you to discuss them with you?
Crowley: We have somebody else in the hospital who keeps an eye on them. And the one thing I would tell people is that when our hospital got the grant, it was before I came. To be honest, they had no idea of how extensive and what the resources would be to implement it. So while it was a great way to get some financial reimbursement for what we were putting in, the effort was much larger than anybody realized that it will be. It was much more of a challenge. I don’t think they quite understood how much work it would be to put in ambulatory EMRs in about 30-35 different practices.
So that really was a challenge and I would tell anybody when you’re looking at grants, you really need to make sure you understand what it will take, because we needed to put in a lot more resources. It was so challenging for us that at one point, we actually did contemplate withdrawing from the grant. We actually had a meeting with the Board. We had a project manager who had left and we were really struggling getting it off the ground. And we really discussed whether we should pull back?
And to be honest, I think the state also thought that we’d pull back. They were thinking, ‘They just don’t seem to be able to make it.’ And in the end, we decided we had to get electronic medical records in these places somehow. We had to just pull everything together and try to get through this, and we went forward with it, which turned out to be the right decision and a wonderful decision. But we weren’t sure at that time that we would be able to do it. So when you’re looking at grants, the statement, ‘there’s no such thing as a free lunch’ really is true. I mean, they really come with a lot of work.
So when they come to me sometimes with some grants, I have to ask, ‘Do we really understand what this will take? Is this really what we want to be putting our energies on?’ So you really have to prioritize the grants also. Is this part of your strategic plan? This was the right move because it’s certainly part of our mission to provide patient safety and good documentation system for our providers. But just because it’s a grant or it’s free money, it doesn’t mean you should automatically go for it.
Guerra: It certainly sounds like—and this probably happen to most places—the person who deals with finding grants should bring anything healthcare IT-related to the CIO so that the CIO can evaluate it and see it fits in with the strategic plan and if the requirements for obtaining the money are manageable. Does that make sense?
Crowley: Right. There definitely has to be a process, and as a CIO, sometimes you have to curb the enthusiasm. And they just say, ‘No, this easy.’ Or I’ll hear, ‘The grant will pay for a project manager.’ Well, the grant may pay for the project manager, but in most cases you still have to find and hire someone. That itself can be a challenge. And the project manager is still going to have to utilize your regular resources within the hospital. And then you have to decide how you’re going to maintain it.
Guerra: It’s interesting. I was just thinking that the objectives may be a little conflicting in the sense that the person in charge of the grant program for the hospital—their job is to get grant money, and so they want to apply for grants and get the money. And in certain scenarios that we’re talking about, the CIO may not find that particular grant worthwhile or manageable. So you may have a little bit of a conflict there of competing interests.
Guerra: That is very interesting. I hadn’t thought about that. I love when I think about things that I haven’t thought about before. And you hit me twice on this interview—first with the urgent care scenario and now with the grant situation. Very good.