Rick Schooler, CIO, Orlando Health
With an ever-growing number of projects on their plate, many CIOs are struggling with prioritization challenges. And what often happens, according to Rick Schooler, CIO at Orlando Health, is that tasks that are deemed urgent take precedence over projects that are essential to an organization’s growth. As his organization continues to expand, Schooler is working to balance immediate IT needs with Orlando’s long-term strategy to deliver a clinically integrated model of care, which is no simple task. In this interview, he talks about his concerns with the proposed MU stage 2 rules, why CIOs will need to put pressure on vendors, the importance of being plugged into the executive team, why enterprise analytics can’t be put on the back burner, and the skillset that today’s CIO must have.
Chapter 2
- HIE sustainability issues
- Having a data platform that brings it all together
- “We need to put pressure on our vendors”
- Plans to attest to Stage 1
- The complex registration processes for EPs
- “We’re scrambling to get it all done”
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Bold Statements
The people who truly do benefit from it, in either a clinical way or in a financial way, are not willing to fund it. Typically they look for health systems to fund these kinds of things, which, quite frankly, we’re all growing a little tired of doing, because we’re building our own HIE platforms.
Many of them pass the Meaningful Use certification based on the ability to manually send and receive a CCD. What’s got to be in place for this to work on a broad scale and on a meaningful scale has got to be the ability for things to automatically as well as manually be generated and received.
If we don’t put pressure on the vendors to deliver code that works, it’s not going to happen. Our vendors have to be incentivized and motivated and, I would add, pressured to get that code usable.
When you look at how involved it is to register one physician, it gets to be pretty significant amount of work. And typically if you employ them, they’re not sitting around thinking that they have to do this. They’re thinking, ‘okay, my employers are going to handle this.’
The problem is you’ve got a whole year of that attestation, so once you’re registered you’re heading down the road. But people have got to realize that if you wait longer to attest for the first phase, that second phase is going to come up quicker than what you may have thought.
Gamble: What is the HIE picture look like in Florida? Are there few different RHIOs going on at this point?
Schooler: I’m going to say you can definitely count them on one hand; I’m just not sure exactly how many are really alive and functioning. I know of two, the Central Florida RHIO and the Big Bend RIO that are the two community-based platforms that have actually accumulated millions of records. There may be two or three others that are either upstarts or that are in some way exchanging data, but I’m not really sure exactly how far they are down the road and if they really consider themselves RHIOs or if they’re really more of a provider-system-type HIE, but there’s a very small number. Over the years, there had been several that have attempted and dissolved because a lot of different reasons. But the primary reason a community-based HIE doesn’t succeed is because of funding. That’s still the case and will always be the case. And it’s going to be the case with the statewide HIEs as well. Unless a given state allocates taxpayer money to cover these things, at some point, those people that are providing the HIE through the state or for the state, depending on how they set it up, they’re going to come knocking and looking for money.
The state of Florida received, I think, $20 million, and they’ve partnered with Harris Corporation to build the Florida state HIE, but when that money’s gone, then it’ll take a few million dollars a year to run that business. And so they’re going to have to find someone to fund that. The first look would probably be to those who are participating in it and using it, I would guess, and they’re not charging folks right now to get on board for the first one, two or three phases of users, but at some point, they begin to charge. And so they’re working through their sustainability model just like the Central Florida RHIO that we have in Orlando is working through its sustainability model. And it all ends up at the same end. Those who use it and who benefit from it should be the ones to pay for it. And that’s not always been the case, which is why most of them failed, because the people who truly do benefit from it, in either a clinical way or in a financial way, are not willing to fund it. Typically they look for health systems to fund these kinds of things, which, quite frankly, we’re all growing a little tired of doing, because we’re building our own HIE platforms for our purposes with our aligned providers.
Gamble: That seems to be the strategy that a lot of the CIOs are taking and it makes a lot of sense to me, because as you said, you’re building your own HIE.
Schooler: You really don’t have a choice because if you’re going to be an integrated health system that has information flowing across the complete continuum, and as that continuum grows beyond the walls of the hospital or beyond the walls of a big clinic or a big practice, when it gets to the point where you say, ‘Okay, now we’re going to play this future state healthcare game,’ then you have to have a platform that can bring it all into one place — or at least make it look like it’s all in one place. And there’s different ways to skin that cat if you will, but that’s the inevitable reality that we’re all facing which you’re hearing from other people as you talk with people around the country.
Gamble: In a lot of these cases, you can just exchange in the name of one state for another and it’s the same thing. There are HIEs that just haven’t been sustainable and there are ones that are working, but it’s the larger health organizations and health system that are reaching out to the community and building their own HIEs and working with each other to some extent, and that seems to be what’s working.
Schooler: Yeah if I need to exchange data with our competitors, we’re actually doing that now through the RHIO because it’s a repository model. But in the future, we’ll be doing that through the state HIE or through our own point-to-point, because remember, as was indicated by Mostashari’s talk at HIMSS, in 2014 there will be a requirement for HIEs and EMRs to be able to share CCDs. And I haven’t been through the details of Stage 2; I’ll probably just read a summary of it — we’re still focused on getting stage 1 finalized here. But we need pressure on our vendors, our HIE and our EMR vendors. They need to be pressured to make this a reality. Today, many of them pass the Meaningful Use certification based on the ability to manually send and receive a CCD. What’s got to be in place for this to work on a broad scale and on a meaningful scale has got to be the ability for things to automatically as well as manually be generated and received.
For example, when we discharge a patient, we want to take that CCD and shove it over to that person’s referring physician, right? Well, I don’t want to have somebody think to be able to do that — that has to happen automatically. When somebody on the state HIE that’s a user in Tallahassee or in Miami knocks on my door electronically and says, ‘hey, do you have any data on this patient I’m seeing?,’ I’ve got to be able to receive that request. My HIE platform or my EMR, depending on how one decides to connect, has got to be able to receive that request and then automatically respond by sending the data out. At the same time if I ask for something through the state network, or if I query directly to another provider to say, ‘hey, do you have data on Rick?’ Well then my systems have to be able to receive all the data that comes back and be able to process it and present it in a way that I can say, ‘I want that and I don’t want that,’ and then dump that into my record or put it in my platform, and then later I can decide if I want to integrate that into my official record. So that’s why we have chosen to put an HIE platform as our touchpoint for all external CCD exchanges or requests, because otherwise, with multiple EMRs do you see what my picture begins to look like?
Gamble: Yeah, definitely.
Schooler: And that helps you understand I think why larger health systems are going to a consolidated platform. If they’ve got one system that does it all, then great, you don’t need an HIE. But the vast majority of us do not have a platform that takes data from everywhere and puts into a consolidated view, unless you’re a smaller facility.
Gamble: That definitely does not seem to be the norm, not from what we’re hearing in talking to people.
Schooler: Right.
Gamble: You brought up Meaningful Use, and from what I’ve heard so far about the proposed rules stage 2, there does seem to be a lot of focus on interoperability, along with safety and patient engagement. Have you had the chance to really look at any of it so far? I mean, it is a 500-page document.
Schooler: I actually read a brief comment that was on Healthcare IT News about how the guy that’s with the Health IT Now Coalition commented that the interoperability was really relaxed and it really wasn’t pushed as hard as it should have been, and I found that to be in direct contrast with what Mostashari was saying about what we expect in 2014 with interoperability. So I don’t know where that’s going to wind up, but I’ll tell you that if we don’t put pressure on the vendors to deliver code that works, it’s not going to happen. Our vendors have to be incentivized and motivated and, I would add, pressured to get that code usable. We want to be Meaningful Users of Meaningful Use, right? Think about it. We really want that to happen and we’re not going to have somebody sitting there trying to manage thousands of transactions a day for CCDs in and out of a platform. That’s just insane to think that’s going to be the case. Well, several of the vendors are not going to have that capability well into later this year or even into next year. And again, that’s an automated capability to send and receive and to request and to respond to requests for CCDs on individual patients or to automatically trigger a sending or a receiving. So in theory, if we all play this game the way that we’re supposed to, all the EMRs will talk to each other point-to-point.
Gamble: That seems like it’s putting CIOs and organizations in a tough spot if you’re saying the vendors won’t have this capability until next year or late this year, it’s like this waiting game just continues.
Schooler: You’re right. And when you go to register for Meaningful Use for your hospital or your eligible providers, you have to specify, of course, exactly which software you’re using and what release. Well, they actually provide, you based on the software vendor, the release that is Meaningful Use compliant. Some organizations are finding that, ‘Wait a minute, I don’t think I have time to get that release installed,’ or, ‘Gee, we know that release has bugs in it.’ I mean, every software product has bugs in it, but if you, for example, delay putting in what has been deemed and certified as Meaningful Use compliant, you can work yourself into a corner where you’ll miss some funding. You’ll lose out on some stimulus because you haven’t given yourself enough time. And I’m not saying that’s the vendor’s fault, I’m just saying, you haven’t given yourself enough time to implement and test and so forth to get that up into production.
So a lot of people have got to wake up and realized that if you don’t want to lose any stimulus money and it’s not the end of the world — you just pick it up next year. But you’ve got to be very cognizant of when your vendor is making that code available, and when they’ve got it deemed certifiable so that when you go to register your eligible providers and your hospitals, you can pick the right system to know that, ‘Okay, what’s here is valid and certified. I have implemented it or will have time to implement it.’ And that’s kind of a gotcha for a lot of people, I think. We’ve run into that with our patient portal technology. So we may not have time to implement that version and may have to go another route to another system to satisfy all the criteria.
Gamble: Now as far as stage 1, you said that you’re working toward attestation?
Schooler: Oh yeah, I mean we’re like a lot of folks. We plan to attest starting in April, but that gives us all the way up to July, if we get delayed, to be able to do it July, August, or September to get it done this fiscal year and then of course our eligible providers have up until the end of December to get attested as well. But in the state of Florida, there’s Medicaid money just sitting on the table. Once you register, you can get that money, you don’t actually have to attest in the way you do for the federal money in the state of Florida. So when you register, there’s a series of things that happen then because you’re indicating that you either are or you soon plan to be within the timeframe on the technology. The money is made available. I think it varies by state how different states do this.
Gamble: It gets a little bit hairy.
Schooler: Let me tell you, the registration process for eligible providers in the state of Florida is very involved, let’s just leave it at that. If you’re an individual physician, it’s just a frustration you have as an individual — maybe there are three or five of you in a practice. But if you’re like us with 350-plus physicians and you’ve determined how many of these are going to go the Medicaid route, which for us is about 175, then that’s 175 doctors that we’ve got to register. And when you look at how involved it is to register one physician, it gets to be pretty significant amount of work. And typically if you employ them, they’re not sitting around thinking that they have to do this. They’re thinking, ‘okay, my employers are going to handle this.’
Gamble: So this can fall under the health system.
Schooler: Well it is in our case; we have a responsibility to get it done. And so those are little nuances that a lot of people don’t necessarily think about until you’re in the middle of it and you realize that registering is not, in all cases, as straightforward or easy as people might think. For some it’s very easy but when you get into registering for eligible providers, the hospital piece is pretty straightforward but the eligible providers, it’s pretty detailed. It varies by state, but it can get very involved.
Gamble: As far as working with the eligible providers, is this something where you either have to form a group or put somebody in charge to kind of help that along?
Schooler: Yes.
Gamble: How have you been setting that up?
Schooler: We have resources that are just dedicated to get the registration done. And we may have waited too long; based on what we’re learning now, we did wait too long to register. They’ve extended the deadline al little bit, but we’re scrambling right now to get it done for the state of Florida, because you have to register first at the federal level and then you go state level.
Gamble: Okay. And on the state level there was an extension?
Schooler: I think they bumped it out by a few weeks, but it’s not six months. So again, two years from now, this will all be history but each time, for each stage, I believe, the attestation has to occur. And the problem is you’ve got a whole year of that attestation, so once you’re registered you’re heading down the road. But people have got to realize that if you wait longer to attest for the first phase, that second phase is going to come up quicker than what you may have thought, and the second phase is obviously more significant than the first. Stage 2 has got more requirements than stage 1, but if you look at how long we’ve had to get to stage 1, I don’t think we’re going to have that much time to get to stage 2. And those requirements stiffen up; they get more significant.
So that alone with ICD-1O and our own strategy, I think every health system is going through the same thing right now. As organizations, I’d say we’re all, on the average, doing more than we should be at the same time. But so much of this we really can’t control — we have to do it. We have to pursue our local strategies. We have to pursue the regulatory requirements. Now we don’t have to pursue Meaningful Use until 2015, and then we still don’t have to because we can accept penalties if we’re not compliant. But throw in e-prescribing and you’ve got several things that we all feel, ‘well, we’re going to do that.’ But they’re all coming at the same time.
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