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.
- Thoughts on Meaningful Use — Good idea, tough timeline
- Physician expectations and the value of education
- Lining up incentives by going “at risk”
- Being a “Pioneer Accountable Care Organization”
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The government is basically putting a forced structure in place where we have to capture the metrics. It’s helped the provider organization on one side, because it’s forcing the vendors to focus and pay attention and create products that are able to capture those metrics and create those measurements.
When physicians start to utilize the electronic health record and they realize the value, our experience has been that they embrace it and they become partners with us and really take ownership of the application. And the more that we can make that happen, the easier that transition is going to be.
We get a per-member, per-month rate for the individuals, for our members, and we provide all the care. And the better we are at providing that care, the more improved the quality of care, the more money we can save. So it’s definitely the wave of the future from my perspective.
When you’re an organization that employs the physicians, the physicians are part of the organization. They are part of the decision-making process, so they understand that if we can reduce the cost for patients, we can save more money as an organization, and that can roll directly through us.
This is kind of a pilot program to test how we can make this work, and I think we need those provider organizations that are more adept at managing populations to work closely with the government and figure out what the best ways are to make it work.
Guerra: Let’s talk a little bit about what the government is up to. How long have you been at Montefiore?
Wolf: Coming up on 24 years now.
Guerra: Okay, so you’ve been in this business a long time. As someone who’s been in this business for 24 years, almost a quarter of century, what are your thoughts around the government’s program in terms of the high-level concept — sometimes things are good conceptually until they become operationalized. But are you a fan of what the government has done?
Wolf: Yes, I would say I am a fan. It’s no surprise and no secret that healthcare can’t continue the way that it’s going today. And what we’ve done at Montefiore with our risk management structure and taking on risk for our patients in the Bronx — and certainly with being selected as an ACO, I think we’ve proven to ourselves and to others that there is a better way, and that better way is for the provider organizations to really start to provide population care management. Because when you’re providing for all of the health needs of a specific population and you are the provider, you get to focus on the right things at the right point in time. And I think the whole concept of Meaningful Use in terms of quality improvement is the beginning structure to get us there.
There is no question, and most people in academic medical centers will say the same thing — you really can’t improve what you can’t measure, and so you really need the metrics. And the government is basically putting a forced structure in place where we have to capture the metrics. It’s helped the provider organization on one side, because it’s forcing the vendors to focus and pay attention and create products that are able to capture those metrics and create those measurements, also creating the scenario for opening up the products and creating better integration across different products. So from that perspective, I think that the government is right in line with where we need to be going. The timeline and the timing of the projects or the Meaningful Use timeline, I think, might be a little aggressive. I’m not speaking to that aggressiveness from Montefiore’s perspective, but from other organizations that haven’t yet embraced electronic medical records and haven’t really started to implement physician order entry and started to actually integrate IT into their day-to-day workflow and work process. It’s difficult to go through that process, and to have a forced march with the timeline on it — that’s a heavy lift for many organizations.
Guerra: Right. You’ve been there 24 years. Some of your colleagues from the community hospitals out there with 200 to 300 beds that haven’t gone on their journey have to cram a lot of the stuff you’ve done over a quarter of century into a couple of years.
Wolf: The good thing is that the vendors have also learned a lot about doing the implementations and helping organizations get started and quickly move forward, and I think the world of physicians is starting to understand that this is what’s happening and it needs to be embraced. When physicians start to utilize the electronic health record and they realize the value, our experience has been that they embrace it and they become partners with us and really take ownership of the application. And the more that we can make that happen, the easier that transition is going to be.
Guerra: You mentioned before when we were talking about physicians that they want that integration between the inpatient and ambulatory worlds; they want to see the same things. Is it difficult getting them to understand why it’s not so easy or why it’s not easy? Do they say to you, ‘why you can’t just do this? Why is it so hard?’
Wolf: There are quite a few people that say, ‘I just need this particular piece’ and ‘why can’t you just do this? I’m able to do this at home. Why isn’t this just like something that I’m doing today with my iPhone or with my PC at home?’ But we educate them and we take them through some of the difficulties. We work closely with the physicians, and certainly the leaders — or, I should say, early adaptors — are super-user physicians that really want to get involved and really want to work closely with us in moving the products forward.
So I think that they understand it, but it’s extremely frustrating. When you have a patient going through a transition of care that’s been your patient on the ambulatory side for a period of time — for example, for a primary care physician, your patient is admitted through the emergency room then discharged, and now you’re working from an electronic medical record in an ambulatory setting, and you’re trying to find the information from their inpatient visit. You have access to it but it’s not integrated with your ambulatory and you’ve got to cut and paste things into the system or you have to toggle between the two systems to say, ‘I want to look at what happened when you were in the inpatient setting and now I want to create a plan for follow-up visits.’ It just makes it very difficult. And what we’re doing in the ambulatory world today, in terms of the volume of patients that our ambulatory physician are seeing, they don’t have a lot of time.
Guerra: Right. They have to see 20 to 25 patients a day at five minutes a shot?
Wolf: Minimal — yes.
Guerra: It’s certainly a tough spot. Let’s talk a little bit about the ACO stuff. You mentioned that you were, as a health system, you used the term ‘at risk’ for a certain number of lives. And this is where you really can educate me, but is that where you’re also acting as a payer — you’ve become a Kaiser-like organization where your incentives are really lined up?
Wolf: Correct. We get to keep any savings that we have in our full-risk population. So for example — and I’m not talking about the ACO now, I’m talking about the 150,000 lives that we’re at-risk for in a capitated world — we get a per-member, per-month rate for the individuals, for our members, and we provide all the care. And the better we are at providing that care, the more improved the quality of care, the more money we can save. So it’s definitely the wave of the future from my perspective.
Guerra: So there is an insurance company involved in the scenario you just talked about, correct?
Wolf: Correct. They actually sign up the member and then they pass through a percentage of the fee to us and then we take on full-risk.
Guerra: I just saw a big study which came out a couple of days ago in Health Affairs where they said that people using electronic systems order more imaging than people are using paper systems, so there’s been a lot of controversy around that study. But one of the takeaways was that whether it’s electronic or paper, if we don’t redefine or rework the incentive structure, we’re not going to reduce duplicate testing. But by taking on lives at risk, you have lined up these incentives. How does that get to the physician level — they just need to understand that they’re not going to make any more money for ordering another test?
Wolf: Well, it really depends on the program. So when you’re an organization that employs the physicians, the physicians are part of the organization. They are part of the decision-making process, so they understand that if we can reduce the cost for patients, we can save more money as an organization, and that can roll directly through us. And these are some programs that we’re currently working through. How do we get the savings back to the physicians — how do we allocate that back to the physicians? That’s a little bit out of my purview or my scope, so I don’t want to comment too much on how that program is being put together, but that’s the concept.
Guerra: And technology does have that to be the backbone of any of these programs. Does that make sense?
Wolf: There is no question about that. Everything from the test results, the orders for the tests, the care plan for the patient — every aspect of it; the transition of care, patients moving actually out of network for certain services and back into network after they acquire those services — all those pieces all come together and it has to be integrated electronic transitions of the information, along with the transitions of care.
Guerra: You had touched on being a Pioneer ACO. Tell us a little bit about what that means and whether or not this is something you recommend some of your colleagues to do.
Wolf: Pioneer is really a shared savings program with the government, so you have to be able to identify savings through care management. So what happens is you have certain quality measures that you have to meet and you’re graded on how well you do against those care management initiatives and you report back to the government, to the Pioneer program on how you’re doing. And then depending on how you score in terms of those quality measures, including patient satisfaction, you get into a shared savings program where you save a percentage or you’re able to hold on to a percentage of the combined savings.
Guerra: Do you think there’s so much going on with some of your colleagues that maybe they figure they have enough on their hands without really exploring ACO programs? Do you think that maybe people are a little overwhelmed and ACO might be the thing that they leave off to the side for now?
Wolf: When you say my colleagues, if you’re talking about the large academic medical centers, the more advanced academic medical centers, my answer would be no. I think they need to be involved in programs like the ACO Pioneer program, and the reason for that is the government is learning as we go. This is kind of a pilot program to test how we can make this work, and I think we need those provider organizations that are more adept at managing populations to work closely with the government and figure out what the best ways are to make it work. I think the program is structured to have that happen. So it’s very important; it’s critical that other Montefiore-like organizations get involved in the program so that we can understand, report back, and help the feds realize what that structure has to be. Because, as I said earlier in the conversation, healthcare can’t continue the way it was going. We’ve got to really perfect this and move forward with it. So this is the opportunity for us to be at the table when those decisions are made and when the structure is built.