Karen Marhefka, Associate CIO, UMass Memorial Health Care, Chapter 1

Despite the fact that many health system CIOs sit on the executive board and play a key role in shaping an organization’s long-term strategy, the perception of the CIO as basically a “mechanic” is still a common one. And it’s one that Karen Marhefka wants to see change, particularly as more hospital functions and departments fall under the IT umbrella. In this interview, Marhefka talks about what it takes to operate a best-of-breed shop in today’s complex environment, the importance of staying abreast of vendor mergers and acquisitions, and the challenges in establishing a strategy that is solid enough to guide an organization but flexible enough to accommodate shifting priorities. She also discusses what it has been like to work with George Brenckle and how the CIO role has evolved and will continue to change going forward.

Chapter 1

• About UMass Memorial
• Allscripts ambulatory, Siemens Soarian acute, dbMotion for integration
• Making a best-of-breed shop work — “It takes very, very smart people to maintain what we’ve built”
• The state of Soarian ambulatory
• Navigating vendor M&A
• The critical CIO-general counsel relationship
  

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Bold Statements

It’s been a long journey in order for our integrated health system to actually be able to act like an integrated health system on the same platform. That enables us to share patient information in the most ultimate way — one chart per patient, no matter where they go within our health system.

With everything that is coming into play as we’re moving on to these integrated health systems with Meaningful Use, ICD-10, getting our data governance structure in place — all of that is still top of mind and interwoven into our strategy that actually was put together over four years ago.

When you have a single-vendor solution who does that for you based on how their products are built, obviously that can be nirvana and a little bit easier from an implementation standpoint and certainly from a maintenance standpoint. But you’re very, very much tied to that vendor for how things flow, and what they decide to do in terms of customization or just upgrades.

I’m one of the nominees to sit on their ambulatory advisory board, even though Siemens knows full well that we are a very large Allscripts Enterprise customer. That act on their part shows me a deep commitment to making sure that they understand the ambulatory world.

That’s probably the biggest reason why I’m not as worried about it, because we have an exceptional office of the general counsel here and our contracts are handled very, very carefully. And I would suggest anyone out there on the healthcare side who’s purchasing software make sure that they have really good contracts.

Guerra:  Good morning, Karen. Thanks for joining me to talk about your work at UMass Memorial Healthcare.

Marhefka:  Good morning, Anthony.

Guerra:  All right, why don’t we start out with the basics of the organization. I know you have a lot of moving parts — acute, ambulatory, inpatient, and outpatient, so just give us the overview.

Marhefka:  We are a very large integrated health system located in Central Massachusetts. We have five acute care hospitals and we have a huge medical group about 1,600 physicians-strong. We’re a little over 1,100 beds when you take into account all of those acute care sites, but we are predominantly within the central Massachusetts area. We have Allscripts as our ambulatory EMR and we just upgraded to Siemens Soarian’s suite of applications for our acute care side. It’s been a long journey for our integrated health system to actually be able to act like an integrated health system with being on the same platform for our health information system. That enables us to share patient information in the most ultimate way — one chart per patient, no matter where they go within our health system, which is the first time we’ve been able to do that ever.

Out of the five hospitals, we only have one left to bring on to the Soarian platform, and when that’s completed, then we’ll have a completely integrated acute care record for our patients as well as the integrated health record for ambulatory side of the house. We were able to pull both of those arenas together — the inpatient information and outpatient information, through use of dbMotion as our clinical portal. So we are well in our way in what we had intended to be our five-year ‘cornerstone journey’. We branded all of this work under a single name given the amount of vendors that we were dealing with in order to portray what we do believe feels like quite a seamless interaction with our information systems. So that branding ended up being cornerstone and we are in the fourth year of the five-year journey.

Guerra:  And do you feel like you’re on track?

Marhefka:  We feel like we’re on track. Obviously with everything that is coming into play as we’re moving on to these integrated health systems with Meaningful Use, ICD-10, getting our data governance structure in place — all of that is still top of mind and interwoven into our strategy that actually was put together over four years ago. So we’ve had to adjust, and we’ll adjust again and again and again, but for the most part, we feel like we’re very much on track.

Guerra:  The goal is to operate like a health system that’s on an integrated platform. We know there are a couple of vendors out there that people are making big investments in to get everything on the same platform. So your goal is to operate as if you’re in that same application environment where everything is on the same database?

Marhefka:  That’s correct. We really wanted to focus on making sure that we had the right product for the right point of care and a lot of our organization, particularly our physicians who practice in the community setting as well as within our hospital-based clinics, really liked the Allscripts offering. And with a one-vendor solution, you’re going to have to give some stuff up. A one-vendor solution does cover all the basis, frankly; that’s why they sell themselves that way. But you do lose on some of the features where you really want to design your system so that it’s really speaking to the service area where the patient is being seen. So we went that route, and that meant something different for the acute care side from the ambulatory side, and Allscripts sort of started that pathway for us. That was the vendor that was chosen first, and then Soarian from Siemens was chosen second, always keeping in line with the fact that we were going to have to bridge that information gap and pull it together to provide a seamless portal for our clinicians, and that was dbMotion.

Guerra:  When you see some of your colleagues in other large health system making a single investment to whatever degree — you could say throwing out major investments to bring in a mega-investment — I guess anytime you see someone making a bet in the direction of the bet you’ve made, it gives you a little pause. Does that make sense?

Marhefka:  Definitely, and there are days when I’m quite envious of their choice and the change of strategy, given that it takes some very, very smart people, which we’re very fortunate to have, to maintain what we’ve built here. And it all is in the spirit of keeping it seamless, but when you have a single-vendor solution who does that for you based on how their products are built, obviously that can be nirvana and a little bit easier from an implementation standpoint and certainly from a maintenance standpoint. But you’re very, very much tied to that vendor for how things flow, and what they decide to do in terms of customization or just upgrades in how they enhance their system moving forward. You are really tied to that vendor and their design and their decision. So yes, I am envious, let’s say, maybe two days out of the week, and glad that we did that we did the other five days.

Guerra:  Well I appreciate your honesty because I think that is an honest portrayal, and probably anyone in your position would agree with you. In terms of Soarian, I interviewed John Glaser a couple of months ago and we talked about how they are coming out with a Soarian ambulatory product. I think they’re going to beta something later this year, with maybe full production a year from then, so maybe a year and a half until something is really out there in full release. And I’m going to qualify my comments with my best recollection of the interview, but I think it’s pretty close to accurate. When you see something like that, does that peek your interest in terms of wanting to monitor how that goes and possibly get to that single database some day?

Marhefka:  It’s going to be a one-step-at-a-time process. Coincidentally, I’m one of the nominees to sit on their ambulatory advisory board, even though Siemens knows full well that we are a very large Allscripts Enterprise customer. That act on their part shows me a deep commitment to making sure that they understand the ambulatory world and aren’t just going to go out and either buy a product or build a product that they feel is going to suffice as a tool off the shelf for ambulatory. I was very heartened to hear that they were putting an advisory team together and also quite flattered, actually, to be approached as a potential member of that Board.

I know that they’re going about it the right way; at least it feels that way to me at this point. As far as what it means for us, it depends I think on which direction they go, because a purchased product where they introduce that into their suite of applications will end up being not so different than we’ve already put together. A product that they build from scratch will obviously be much more integrated, but that’s going to take a while, and it will go through all of its life cycles of alpha and beta and then introduction into the mainstream. That takes time, and so all those factors are going to play into any different directions that we might take given that we are firmly now a Soarian customer, alive and well, at least on the acute care side.

Guerra:  It must be a fascinating dynamic because you have Siemens in the inpatient setting, and they of course would love to get your ambulatory business that Allscripts has right now. You have Allscripts in the ambulatory setting, and they would love to get into your inpatient business with their Eclipsys product, but as you said, those are two different products, and I don’t know to what degree they’re integrated. So they both have difficulties with their pitch because the Siemens product is in progress and the Allscripts inpatient product is not truly integrated.

Marhefka:  That’s correct.

Guerra:  That’s an interesting dynamic. You must get a lot of lunches and calls.

Marhefka:  Oh definitely, and I’ve told them both. Again, these are two companies and this is why we’re so closely associated with them. These are two companies that really want to do the right thing. And I’ve had this conversation with both of them, and they both acknowledge this — what they don’t know is a lot in the arenas that they’re trying to fill the niche of the thing they don’t have yet. So they’re approaching it, and I’ll repeat myself on this, I’m very heartened in a way that they’re approaching it, which is to reach to their customer base, where they clearly know they have little chance of turning them around to purchase something that they’re going to bring into their suite of applications.

They are trying desperately — and I see this with a lot of vendors these days — not to be the Sam’s Club of tools. They want to understand how an integrated delivery system works, and they want to approach their sales cycle, their implementation, and their support modes because their customer is an integrated delivery system; not because  they have this very cool application that’s worth the sale and is going to fix this one thing. They know that they have to approach their customers now as a solution for many things. So both Allscripts and Siemens are doing that. We work with  a couple of other vendors as well — I mentioned dbMotion a few times, but they all seem to be reinventing themselves a little bit so that they understand the business much better so that they can approach their product sales in a different way.

Guerra:  When you say reinvesting, I assume you mean that in a positive way and not just the marketing way.

Marhefka:  I do. I mean, in the end, a vendor has one thing to do, and that’s to sell software

Guerra:  Sure.

Marhefka:  That’s why they exist but they’re not going to do that, again, just to say, ‘hey, we’ve got these cool tools. Come look at them and buy them.’ They have to understand the business now. It’s just too complex; there are too many moving parts just how with healthcare is reinventing itself. So I meant what I said — what they don’t know is a lot, and they know that. So the more conversations they have with their customers, the more openness they have with — and reinventing themselves may be a strong term, but really trying to look at their process from sales through the support and how that is really embracing how healthcare is changing and what their customers truly need.

Guerra:  So based on what you’re saying, we have seen moves in the past; maybe three or four years ago we’ve seen acquisitions that you don’t think we would see today. For example, when you see a major vendor acquiring a niche software company, and just from a marketing point of view, putting it under their product umbrella, you think we’re beyond that and that they’re not going to fool anyone with that anymore. Does that make sense?

Marhefka:  Every contract we sign now, we know we’re at risk for by the contract being assumed by somebody else.

Guerra:  Right

Marhefka:  I mean, that’s just a fact of life. And we’ve gotten to the point where we’re so used to it now that we anticipate it, and we don’t actually worry about it. It’s the game they’re in and unfortunately we have to play along. It hasn’t hurt us. There have been a couple of acquisitions under prices; there have been a couple of acquisitions for our enterprise master person index solution. We bought that one when it was under the Initiate label and now that’s under IBM. A couple of the Allscripts tools were something else before and now they’re Allscripts. So it hasn’t really hurt us or set us back at all, and I don’t know if we’ve just gotten used to it so we kind of don’t worry about it or if we’re not paying enough attention to it for what it’s going to mean for us in the long run, but right now, it hasn’t been a problem.

Guerra:  Right. And these things can be handled well or poorly by the vendor in terms of communicating. And so you’ve seen both?

Marhefka:  Right, they can be. And my best friend in this organization is our chief legal counsel who looks over these contracts and actually predicts the buy in the future and protects us from that standpoint. So now I’m going to revamp a little bit what I just said. And that’s probably the biggest reason why I’m not as worried about it, because we have an exceptional office of the general counsel here and our contracts are handled very, very carefully. And I would suggest anyone out there on the healthcare side who’s purchasing software to make sure that they have really good contracts with the anticipation of a purchase by another vendor.

Guerra:  I interviewed a CIO recently who said that he has not been able to find a way to insert something in the contract that prevented a vendor from being acquired. So maybe what you’re talking about is some kind of protection if that happens and not preventing the actual acquisition.

Marhefka:  Exactly, because you can’t do that. I mean, that’s really hard if not impossible. So our protection has always been, ‘If this happens, honor the contract for this and take everything forward under a new regime.’ But we’re protected for what we purchased and that’s actually been very helpful, and that’s probably why I haven’t had to worry about it, because it hasn’t hit us negatively when that’s happened.

Guerra:  Right, I wonder if that’s a challenge that smaller organizations have — not getting that really high quality legal advice with contracts.

Marhefka:  I would definitely agree with you that that could be the case. UMass Memorial has a team, I believe, of over 14 lawyers, and we actually have one or two attorneys whose entire workload is our contract management for IT.

Guerra:  Wow, that’s a nice specialization to have today. I think if I were to write up something that would keep me employed for the next 20 years, it would be legal work specializing in HIT contracts.

Marhefka:  And they are tough. And our vendor partners know our particular attorney that handles most of our contracts by her first name, so they know it’s going to be a tough negotiation, but it’s paid off.

Guerra:  Tough but fair, right?

Marhefka:  Tough but extremely fair.

Guerra:  Now regarding Allscripts, the customers that have the Eclipsys and Allscripts products I’ll always ask about the acquisition and how it’s gone, but you don’t really have to care, do you? Because you just have the Allscripts product; you don’t really have to care how well they’re integrating with Eclipsys, do you?

Marhefka:  Well I don’t because we don’t have Eclipsys here, but as a vendor, I want them to be successful. Their success continues to be our success, even though we only use the Enterprise application, which is their largest product on the ambulatory side. It’s all about your colleagues and keeping abreast of what’s going on across the country in other health organizations that are as large as the one I work for to stay in tune with what they’re doing and where they’re moving to. And I have plenty of colleagues that I speak to almost certainly on a weekly basis, if not more, that are an Allscripts Enterprise Eclipsys customer, or at least driving toward that. So we’re rooting for them and hoping that this is going to work well because it speaks well for Allscripts, which means they continue to put lots of dollars into their products to enhance them. As long as they’re in good standing, that means Enterprise is in good standing, which means it continues to be a good product.

Chapter 2