John Bosco Talks About Allscripts

John Bosco, CIO, North Shore-LIJ Health System

In the fall of 2009, North Shore-Long Island Jewish Health System made waves when it announced a monster deal with Allscripts to subsidize up to 85 percent of EMR costs in the offices of 7,000 affiliated physicians. More than two years later, the program is making progress, and although it isn’t moving along quite as quickly as the organization originally anticipated, that’s not necessarily a bad thing, according to CIO John Bosco. In this interview, Bosco talks about the massive educational efforts underway in the community and how North Shore-LIJ is dealing with the unique challenges facing small practices. He also discusses the organization’s efforts to deploy EHRs in a way that will enable them to achieve true value, why CIOs need to pay more attention than ever before to talent acquisition and retention, and the importance of projecting a positive image.

Chapter 1

About North Shore-LIJ
EMR subsidy program with Allscripts
Challenges for small physician practices
Letting Allscripts take the lead
Holding community forums to educate docs
“The huge cultural shift” that needs to happen

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Bold Statements

We’re finding that physicians are doing the smart thing; they’re looking around, they’re assessing their options, and they’re talking to other vendors. They’re not jumping into anything without making sure they’re comfortable with it

It really has propelled us into the world of connecting with non-employed physicians and helping them with EMRs and helping with some basic level of data exchange, which is so much of what’s going to be involved in payment reform and healthcare transformation.

The physicians are not comfortable with us potentially having access to the data, and so we went out of our way to say, ‘Allscripts is installing the system. They’re going to do the training, they’re going to do your ongoing support, they’re going to do the activation support, and they are hosting the helpdesk. We do not have access to the data.’

With the ACO environment and PCMHs, all of these care coordination models are going to require providers to work more closely together. And what we’ve found during this — and we expected it, but not to the degree that we found — is that is a huge cultural shift that is not going to happen overnight.

Sometimes these small practices live in silos. I’m sure they have other physicians that they regularly communicate with and refer to, but for the most part they can be very insulated from a lot of the things that are swirling around the rest of us in the hospitals and the things we fret about and stress about every day.

Gamble: Hi John, thanks so much for taking the time to speak with us today. Why don’t you start off by telling us a little bit about your organization? I know that you have a pretty big health system, so if you could talk about what you have in the way of number of hospitals and things like that.

Bosco: Sure, my pleasure. First, North Shore-LIJ or Long Island Jewish Health System is located in the New York City area. We service Nassau County on Long Island as well as most of the other boroughs of New York City. We have 15 community hospitals and five tertiary campuses that are all pretty closely geographically located; there’s probably only 30 miles between the hospitals that are furthest apart. So we have 15 hospitals, all pretty closely together and in the New York City area.

We’re in a lot of different businesses, as a lot of large integrated delivery systems are. We’ve got several hundred ambulatory centers, including physician offices, urgent care centers, and pretty shortly, freestanding ERs that are all spread within proximity of our hospitals. We have a very large homecare business; we do over a million homecare visits a year. We have a lab that does a lot of outreach business in the area, a hospice care network, a very large research institute — the Feinstein Institute for Medicine, which is a databank for genomics and is connected to centers around the world. So we have a very large delivery network that does about $7 billion in revenue.

We are a large employer — the largest on Long Island. We’ve got about 45,000 employees, which makes us, I think, the ninth largest employer in New York City, which is something to be compared to. We have about 10,000 nurses and 10,000 physicians, and have primarily a voluntary model in terms of our physicians that varies a little bit from hospital to hospital but in general we’ve got about 2500 to 2600 employed physicians, and we’ve got about 8,000 physicians in private practices in our communities who would admit to our hospitals. So that’s the overview.

Gamble: You have a lot going on. You mentioned freestanding ERs — is that something that’s in the works right now?

Bosco: Yes it is. We’ve got a couple of places that we are considering, one being in lower Manhattan where St. Vincent’s Hospital used to be. That closed over the past year or two, and so that community down there is very much in need of additional services, and so we’re opening a very large ambulatory center there over the next couple of years that will also include a freestanding ER.

Gamble: Okay. So you talked about the physicians that are affiliated with the system. One of the things I wanted to talk about was the big Allscripts deal where North Shore-LIJ announced it was subsidizing EMRs for several thousand physicians. This was, I believe, in the fall of 2009. Can you talk about how that program has worked out and the progress that has been made since then?

Bosco: Sure. We announced back then to all of our affiliated physicians that we would subsidize them the full amount for allowable items if they would join our network which was to install Allscripts’ Enterprise version of their ambulatory EMR. We had two levels of subsidy: they could get 50 percent subsidy just by agreeing to install the EMR and agreeing to some basic level of clinical data exchange for treatment purposes, or they could go for the larger subsidy — the 85 percent subsidy — which means that they want to work with us and provide some amount of data from their EMR to help us with population health initiatives and quality initiatives and things like that.

So that was the announcement that we made. It took us a little while to get the program off the ground working with both employed and affiliated physicians so that we really had a model that they were comfortable with. And we’ve had pretty good success — slower than I think we anticipated or hoped, but maybe looking back that was a good thing, because there are a lot of difficult lessons to learn along the way and a lot of challenges. But at this point, after about a year and a half or maybe two years of actually signing people up, we’ve got a couple of a hundred practices, a few hundred physicians that have signed up, with about three-quarters of them live today on their EMR.

And so those are big numbers when you’re talking about a couple of hundred practices, and yet compared to the size of the affiliated physician population out there, it’s not as big a number as we had hoped. But we’re finding that physicians are doing the smart thing; they’re looking around, they’re assessing their options, and they’re talking to other vendors. They’re not jumping into anything without making sure they’re comfortable with it, and so I think for that reason it’s gone a little bit slower, and it’s taken some time to get out there and really provide some education and awareness about EMRs and about our program.

A couple of months ago, we added the Allscripts MyWay product to the program, because one of the lessons that we learned was that the Enterprise version has been a little bit more difficult and challenging for a small practice to use than we had anticipated. And so while they’re using it and they’re happy with it for the most part. When we felt that MyWay was ready to deploy to the physicians and when we worked through some of the issues around MyWay being separate instances and databases of the system for each practice and how do we push data out and draw data from all of these multiple instances — once we worked through that and were comfortable offering it, we added it to the program. Of our 8,000 physicians, over 50 percent of them are solo practitioners, and the overwhelming number of those 8,000 physicians are in very small practices of three to five at most. We have very few large practices here, and so we feel MyWay is more suitable to a small practice. Since we added it to the program a couple months ago, we’re really getting a lot of interest. We’ve already signed up probably close to 20 practices and we have at least that many that have asked for contracts and are interested, and so this may be an additional boost to help us get additional practices signed up.

But all in all, we’re happy with it. We’re starting to move some data around between EMRs and do some very basic work around extracting information. And so I think there’s been a lot of good lessons learned and it really has propelled us into the world of connecting with non-employed physicians and helping them with EMRs and helping with some basic level of data exchange, which is, of course, so much of what’s going to be involved in the payment reform and healthcare transformation that’s going on and swirling around us. And so I think from that perspective too, these are all very valuable learning lessons for us.

Gamble: Absolutely. Now because you were dealing with so many smaller practices, do you know if maybe their hesitancy had more to do with what’s going to happen to our data or if it was a matter of, ‘we don’t really have the manpower to be doing this right now.’

Bosco: I think it’s those two things and about ten more, and then I would just say that it’s all of the above — just tremendous challenges for them. Certainly, as you said, if it’s a physician and their spouse as the front desk receptionist, it’s challenging for them to use an EMR and challenging to install it. You go in there thinking, ‘Well, in order to make the economics work of this installation and what we planned it was going to cost us, we need to get in and out of there in 12 weeks’ with all the appropriate training and onsite activation support and all of those things. And then you get into the smaller practices and you find out somebody’s going to be on vacation for two weeks and then one of the very few help that they have there is on leave. There are a million reasons why in such a small practice it’s hard to just say, ‘This is what the plan is for the next 12 weeks and we can’t veer from it.’

And so that’s been a challenge, and maybe in many cases, the lack of comfort and familiarity with technology in general can be an issue. If they’re not used to having all of this technology around and not used to using a system as complicated as an EMR, that can be challenge. So there are just a whole lot of them, and you work through them. We took the approach of, number one, you mentioned another thing about their comfort level of us having the data — before we started the program or really officially launched it and started signing contracts, we talked a lot to them, and that was a major concern of theirs. So we designed a program to try to make them comfortable that that would not be the case. We sit a little bit in the background at the beginning — it’s Allscripts that is doing a lot of the marketing and sales with us just helping out and Allscripts that is hosting the system. And so the idea that the data would be in our data center where whether we promise or not, the physicians are not comfortable with us potentially having access to the data, and so we went out of our way to say, ‘Allscripts is installing the system. They’re going to do the training, they’re going to do your ongoing support, they’re going to do the activation support, and they are hosting the helpdesk. We do not have access to the data.’

There are a lot of pages of our subsidy agreement with the physicians dedicated to all the things we’re not allowed to do. So we tried to be very upfront and say, ‘If you join either one of these programs, here is very specifically what you’re agreeing to in terms of data exchange for treatment purposes, and in the higher subsidy level, here is very specifically what you’re agreeing you will provide to us, and that by default, we’ll have access to nothing else, including all of your financial information,’ and so on. So we try to design in a way that would make them more comfortable.

But I think that one of the big challenges in all of this — and it’s going to be a challenge for all of these different managed care arrangements that are going to be coming down the pike — is that we are rapidly moving to a place, and we need to, where physicians are working more closely with other practices and with hospitals. With the ACO environment and PCMHs, all of these care coordination models are going to require providers to work more closely together. And what we’ve found during this — and we expected it, but not to the degree that we found — is that is a huge cultural shift that isn’t going to happen overnight, and it’s not going to happen in a year or two.

Gamble: Right.

Bosco: One of the things that we did to try to help was we set up these community forums where every Tuesday night — and now we’re down to doing it about once a month — we would go to a community and invite physicians to meet with us. We’d spend about an hour talking to them about healthcare transformation, the HITECH Act, stimulus dollars, and all of the different types of reform and transformation going on, and then we’d spend about an hour demoing the Allscripts system and talking to them about our program. And what we found is a lot of that is needed and continues to be needed, because sometimes these small practices live in silos. I’m sure they have other physicians that they regularly communicate with and refer to, but for the most part they can be very insulated from a lot of the things that are swirling around the rest of us in the hospitals and the things we fret about and stress about every day that are going on now with ICD-10 as well as reform.

And so I think that continues to be a challenge. And I don’t know if that’s true in all areas of the country, maybe some are more ahead of the game, but in our area of the country, it is still the case that there is an enormous cultural shift that needs to take place in order to achieve all the things that we’re talking about.

Chapter 2 Coming Soon…

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