Montefiore Medical Center prides itself on being a forward-thinking organization. The Bronx, N.Y.-based system began implementing an EMR in the mid-90s, and was closing in on full CPOE just a few years later. But although the organization has always embraced innovation, CIO Jack Wolf believes what is just as important is maintaining a sound strategic plan. In this interview, Wolf talks about the weighted decision of whether to transition to a fully-integrated system, the need to be able to seamlessly connect the acute and ambulatory worlds, and how he dealt with being blindsided by a vendor decision. He also discusses Montefiore’s participation in an ACO program, the health IT workforce shortage, and his thoughts on MU Stage 2.
- About Montefiore
- Running a GE Healthcare IT shop
- Montefiore’s clinical IT journey
- Amalga, Caradigm, Qualibria
- Thoughts on big-ticket enterprise EMR buys
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I think that GE’s plans to create an integration capability between their products, as well as an open environment for connecting to other systems, is strategically a perfect combination, given where we are with our accountable care organization, and where we see the future of healthcare going.
Our physicians have a real problem with the way the system is structured today. I also need the capability to bring in reports and orders from voluntary physicians in and around the community. So I do need that integration capability with non-GE systems to occur smoothly.
I really have to weigh what I actually get in replacing GE with another product. If I’m not going to leapfrog where I am today, how can I possibly justify that kind of an investment? And that’s the constant struggle that goes on in my mind.
I can pull out our strategic plan for Montefiore and I can look at all of the IT initiatives that support that strategic plan. And when I look at the plan, I can see the major pieces and where they fit. I wouldn’t say it’s as much what contracts I have coming up that are close to expiration, as where is the window of opportunity to make a change.
Making a large decision like replacing or implementing a large application that spans all of your locations in all of your associates in the organization, that’s not a point-in-time decision; you make that kind of a decision over time.
Guerra: Good morning, Jack. Thanks for joining me today to talk about your work over at Montefiore. I really appreciate it.
Wolf: Good morning, Anthony.
Guerra: Okay, why don’t you tell the listeners and the readers a little bit about Montefiore — those who are not quite from our area. As I said before we started the recording, I’m in a few minutes outside in the city and you’re in the Bronx, so we’re enjoying the same weather today. But why don’t you tell everybody a little bit about Montefiore so they can understand the context?
Wolf: Sure. Montefiore is a fairly large academic medical center located in the Bronx, N.Y. We’ve got just shy of 1,500 beds; we have four hospitals, including a children’s hospital attached physically to our main hospital location on that campus. We have probably about 75 ambulatory sites throughout the Bronx, Upper Manhattan, and Lower Westchester. We do about 90,000 discharges a year. We have very large volume in our emergency rooms; we do over 200,000 emergency room visits a year, making us in the top four or five busiest emergency rooms in the country. We do a little over 2 million ambulatory visits a year across our ambulatory network.
We’re the teaching hospitals of the Albert Einstein College of Medicine, with close affiliation with the college. And we also provide most of the primary care for our patient population in the Bronx, which makes us a little different than your typical academic medical center. We have 150,000 lives that were at full-risk for, and we are a recipient of the Pioneer Accountable Care Organizations project, and we’re also in health homes.
Guerra: You certainly are a busy man. I guess your to-do list always has something on it, right.
Wolf: We’ve got quite a few projects going on at any given point in time, and this year, more than many.
Guerra: Right. Okay, so you have 75 ambulatory sites and four hospitals. Let’s get into your application environment a little bit and the genesis of this conversation, which was seeing that you had attested to Stage 1 using GE Centricity products, both inpatient and ambulatory. There’s not a ton of Centricity site out there. I interviewed Tom Ciccarelli, who you may know, over at East Orange in New Jersey, who runs a GE shop. But just give me an overview of how GE has done for you and what you see as the go-forward strength or strategy around Centricity. We’re all making bets — we just saw what happened with McKesson with a shift in their focus from Horizon to Paragon. Just give me your overall thought on GE as a partner going forward and how things are going.
Wolf: I’m going to have to take you back in time a bit to answer that question.
Guerra: Feel free.
Wolf: We started looking for an electronic medical record in the late 80s into the early 90s. We knew that we needed to automate, and an electronic medical record was the way to go. The President of Montefiore at the time issued the challenge to break the pencil, meaning he wanted all orders online. Now we’re talking 1989 and the 1990s, so he was kind of ahead of his time in that respect. In 1993, we met with a company called Phamis, which was the electronic medical record for the Public Health System in Seattle. And they were attracting merchant marines at the time, I believe. The two founders of Phamis were actually Einstein graduates and one of them had done a residency at Montefiore, so it was kind of an interesting relationship to start out. We acquired the product, signed the contract, and started our implementation around 1995, and we were closing in on a 100 percent CPOE in 1998-1999. So we were a bit ahead of the curve in terms of physician order entry. The company Phamis was acquired by IDX in that process, and then IDX was subsequently acquired by GE. The joke at Montefiore is that GE acquires every company that we buy a product from.
So we also run the GE PACS system, which we actually acquired from GE, and about two or two-and-a-half years ago, we started implementing the old Logician — the new Centricity EMR product from GE. And we’re closing in on completing that project probably into the end of the third quarter of this year, rolling it out across all of our sites, including many high schools and elementary schools across the Bronx. So we’re providing care right in the school systems using the Centricity EMR product.
Guerra: I’m just looking for a little more from you around how GE has performed for you. This is really for the benefit of your peers who are listening to this call. Are you comfortable with them taking you forward at this point?
Wolf: It’s always been interesting to watch GE in their development. Montefiore has been a development partner with GE for a number of years, and we’ve had a great success with developing products with GE. GE has been moving with their product with a lot of development activity at Intermountain Health, as I’m sure you know, and at the Mayo Clinic.
Wolf: The relationship with Intermountain hasn’t really taken the product where I think GE wanted it to go. The Core Centricity enterprise product, the inpatient product, we feel, is a phenomenal product. That’s the Phamis product that moved through IDX into GE. And I think that GE’s plans now to acquire Amalga and build Caradigm, the new combination of Amalga and their own product, Qualibria, to create an integration capability between their products — Centricity Enterprise, the inpatient side, and Centricity EMR, the ambulatory product — as well as an open environment for connecting to other systems, is strategically a perfect combination, given where we are with our accountable care organization, and where we see the future of healthcare going and the integration requirements as the HIEs start to take hold and RHIOs start to really combine with HIEs and transform us into population health centers across multiple separate provider organizations. That concept is going to be the only success factor that’s going to exist among the large vendors. So I think GE has the direction correct at this point in time. GE has always struggled in that product development, but I see the team now starting to focus, and I’ve got a very positive feel for where they’re going with their product.
Guerra: Right now, would it feel like you’re essentially operating on two systems? You have Phamis or IDX in inpatient, and then essentially Logician, which is now called Centricity on the ambulatory side. Is it pretty distinct in terms of two databases where there’s not much flow going on there?
Wolf: They’re starting to develop integration between the two interfaces, but there’s a long way to go on that. And yes, it does feel quite a bit like you’re operating on two separate systems.
Guerra: So when you see a lot of health systems making these big enterprise buys to get on one platform, does that resonate with you? Do you say, ‘that sure would be nice,’ or you say to yourself, ‘listen, at some point I have to connect up anyway. Even if I connect up internally in my acute and ambulatory world, I’m going to have to connect with other organizations, so what’s the difference?’
Wolf: I really need to connect my ambulatory and my inpatient worlds. That’s been an issue for us; our physicians have a real problem with the way the system is structured today. I also need the capability to bring in reports and orders from voluntary physicians in and around the community. So I do need that integration capability with non-GE systems to occur smoothly. As we move forward into the accountable care organization world, I’ve got to be able to take my care plans from my care management system and merge those into the electronic medical record, both on the ambulatory and the inpatient side, so we can see the care plan for the patients or members that we have responsibility for in our risk structure. And so all of those pieces have to come together.
When I look at the industry and I see out there, you’ve got Cerner, you’ve got Epic, you’ve got Eclipsys, you’ve got Siemens — you’ve got a lot of huge and very complex systems. You know, we’re sitting here with a GE product and there are all a lot of shortcomings with the GE product that we’re working with GE to address, but I can’t point my finger at any provider organization that is significantly further along with information technology than Montefiore. And when I say that, I say to myself, for me to go out and acquire a product, there’s a significant cost involved in making that transition.
So I really have to weigh what I actually get in replacing GE with another product. If I’m not going to leapfrog where I am today, how can I possibly justify that kind of an investment? And that’s the constant struggle that goes on in my mind. Could I take an Epic product and put a fully integrated solution on the table for my physicians? And if I did that, how much further along would I be than where I am today? That’s a difficult question to answer.
Guerra: Because you have to sell it right? If you decide you want to go down that direction, that’s a big sales pitch, right? That’s a big egg to lay in front of the board and say, ‘hey, I need a little more money next year.’
Wolf: It is, especially when you’re juggling a lot of factors. You’ve got a decision on the electronic medical record — do I stay with GE or do I look for an alternative? At the same time, we’ve got Meaningful Use Stage 2 on the Horizon, we’ve got ICD-10 on the Horizon, and I’m right into replacing my laboratory system, which is the next 24 months of head-down activity for my clinical staff. We’re also doing a major refresh in our human capital management area, so I’ve got some huge projects going on, and bringing a project like replacing our EMR forward is a difficult decision.
Guerra: I was just thinking, there isn’t source of a constant level at which these things are evaluated, because you’re locked into certain contracts and things like that. So there are points in time during the year or during a few years’ span, when decisions really come to the forefront — when you either have to double down on what you’re doing, or decide it’s a good time to reevaluate your options. Does that make sense and do you in your mind know those points like right up to the top of your head — for example, in six months, we’re going to do this, and this means we’re going to stay the course for the next couple of years?
Wolf: Well, we’ve got a pretty good plan mapped out, so I can pull out our strategic plan for Montefiore and I can look at all of the IT initiatives that support that strategic plan. And when I look at the plan, I can see the major pieces and where they fit. I wouldn’t say it’s as much what contracts I have coming up that are close to expiration, as where is the window of opportunity to make a change.
For example, out of leftfield, GE sunset the laboratory system that we currently run — the old Triple G Ultra system. GE acquired them shortly after we acquired the Ultra product; thus my comment about GE acquiring everybody that we buy a product from. But that was a large project that kind of blindsided us a bit, because we didn’t think that we were going to need to replace our lab system at this point in time. So we threw that into the mix with Meaningful Use, ICD-10, and all the other projects on our plate, as well as the whole implementation of a replacement care management to handle all of our new requirements as accountable care organization. So it was a very difficult decision to make in terms of timing, but it was like the burning oil rig — I knew there was no way I could stay in the lab system without GE providing support for it. So obviously I had to make that change.
Making a large decision like replacing or implementing a large application that spans all of your locations in all of your associates in the organization, that’s not a point-in-time decision; you make that kind of a decision over time so you really have the luxury of thinking through when you would do it in a situation like, ‘are you going to replace your EMR’ or ‘are you going to replace your HCM system’, and sometimes it gets thrown at you like our lab system did.
Guerra: I’m guessing when you get the call or somebody stops by to visit you from GE to tell you that the lab system was sunsetting, that you were not very happy with that information.
Wolf: Livid is the word that comes to mind.
Guerra: Well, I guess a lot of your colleagues go through that. It’s part of the job, right? You invest with the company and next thing you know they’re acquired and the people making the decisions are not the people you made the agreement with. CIOs find themselves in this situation all the time, correct?
Wolf: Not all the time, but more than we should.
Guerra: There’s not much you could do about it, right? Is there anything you can do contractually to guard against some of this stuff or give yourself out-clauses, or is that just not practical?
Wolf: I’ve never been successful in trying to get a clause like that in a contract. And even if you did, you’re not going to stop a company that’s sunsetting a product. It’s just impossible to do that, and you don’t want to be the last customer sitting on a product with very limited support.
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