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.
- Educating docs about HITECH
- “This is not a time to rest.”
- Allscripts Sunrise for inpatient, Enterprise for employed docs
- “We were not early adopters of EHRs.”
- The ripple effect of the ICD-10 delay
- Staying positive during tough times
- Who has it tougher — small community hospitals or large organizations?
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We’re not trying to throttle it or govern it in any way; we’re just going to continue to go out in the biggest way we can and sign up as many physicians and accomplish as much as we possibly can.
We were not one of the early adopters and investors in EHRs. I wish we were, because I’d love to be done and focused on these other things, but, like probably most of the country, we’re still deploying EMRs while we’re trying to figure out how to get the value out of them and how to use the data that’s coming from them.
We’re trying to move as quickly as we can, but with an eye toward making sure we’re doing it in a safe way and in a way where we are accomplishing what we want to accomplish. And so we’d love to get as much as of that stimulus money as we can — and in a place this big, that’s worth a lot of money — but that’s not our primary focus.
It’s a challenge for us to deal with all of these things at once, and I think it’s even more of a challenge for smaller and medium-sized places or places that are struggling more than we are financially.
To keep attracting that number of people and assimilate them into the organization and make them feel comfortable and happy to be here takes a lot more effort than it used to be. We pay a lot more attention to talent acquisition and retention nowadays than I ever remember in my career having paid attention to.
Gamble: I’m sure the educational sessions that you’ve had probably are really serving as a very helpful resource for them, not just about this specific EMR program, but like you said, about things like HITECH that otherwise people just might not be able to get all the latest information on. So I’m sure that that’s really valuable to them.
Bosco: I hope it is, and I know that I personally, and couple of folks like my CMIO, Dr. Michael Oppenheim, feel like we’ve been a help in that area. Sometimes we’re just the messengers to be shot at and take some target practice because you know there are some physicians who think this is a big government conspiracy to get their hands on their data, and to some degree, they’re probably right about that, but to try to stay focused on the patient aspect of it and always do what’s best for the patient is what we try to push. But I think that Mike and I have learned as much from all of them — the challenges that they face and the fears and the stresses — as they have about us in our program.
Gamble: So going forward, are you taking more of a slow and steady approach and seeing this as a long-term program and a long-term effort?
Bosco: I think it is a long-term effort, and I think we knew that from the first place. I can even remember our CEO counseling us in our early meetings when we decided to do this to say, ‘If we’re going to do this, we’re in it for the long term. This is not something that’s going to happen quickly.’ I think he was, as he always is, a lot smarter and more visionary about these things than the rest of us were. I wouldn’t ever use the word ‘slow’ though about anything that’s going on in the healthcare or healthcare IT. We’re not trying to throttle it or govern it in any way; we’re just going to continue to go out in the biggest way we can and sign up as many physicians and accomplish as much as we possibly can.
Because, and I know all CIOs in healthcare feel this way, nowadays it feels like things are moving forward faster than sometimes we feel like we can keep up with and deal with, especially in the IT world where there are systems and capabilities that you need to put into place that just don’t happen overnight. They just don’t happen quickly. Building robust analytics capabilities with integrated data across operational clinical and financial areas is not something you throw up in six months in a big place, just as an example. So we’re always living with this feeling that we just better move as fast as we can all of the time. This is not the time to rest or to spend too much time in doing analysis; it’s a time to really move forward as quickly as we can and hope that we keep up.
Gamble: Right. So as far as the hospitals, what is the clinical environment there? What is the primary EHR system you’re using?
Bosco: We are an Allscripts customer in all of our care environments. We’ve got their system in our EDs. We are still in the middle of our deployments — we were not one of the early adopters and investors in EHRs. I wish we were, because I’d love to be done and focused on these other things, but, like probably most of the country, we’re still deploying EMRs while we’re trying to figure out how to get the value out of them and how to use the data that’s coming from them, and all of these things that have to happen at the same time. I like to say to my CMIO if he had gotten all of this done before I got here, this job would’ve been a lot more fun.
Gamble: Oh yeah, sure.
Bosco: But it’s a big investment for a place like this to make in EMRs, and so it took a lot of convincing and selling on his part and he did a great job getting it done. But we’ve been a little bit later to the game, as most of the country has. And so we have Allscripts in our EDs and we’ve got it out there, and by end of this year in four or five of our 15 EDs we are going full-bore on the inpatient side with what was the Eclipsys product, Sunrise, and is now the Allscripts Sunrise system. And we’re using the Allscripts Enterprise ambulatory EMR for our 2500 employed physicians as well, and so we got a few hundred of them up and we’re doing a few hundred a year.
In our hospitals, we’ve got five that are fully up and we are in three right now. So we’re trying to move as quickly as we can, but with an eye toward making sure we’re doing it in a safe way and in a way where we are accomplishing what we want to accomplish. And so we’d love to get as much as of that stimulus money as we can — and in a place this big, that’s worth a lot of money — but that’s not our primary focus. We certainly want to avoid penalties, because that too adds up to a lot of money, but we’re trying to roll it out in a way where we’ll get some amount of the stimulus money. Because our focus is really on putting out a system that is going to improve patient safety and give us all of the benefits we’re looking for, and not just to slap something up because speed is important.
Gamble: Right, absolutely. I imagine that most your focus right now and probably for the near future is in on EHRs. But what were your thoughts on the announcement around ICD-10 as far as getting more time to focus on other projects and get some of these other things in order?
Bosco: Well I wish they’d come out with a date, because when the announcement first leaked out and then Kathleen Sebelius said something, we decided to take the approach that we were going to slow nothing down until we know what the final date is. In addition to just the whole ICD-10 transformation, we do have some initiatives where we were really up against the wall in timeframe and having to be extremely aggressive to finish some of these initiatives because we had to be done by the ICD-10 deadline, because the systems that were being used could not be remediated. And so in some cases we decided to put in different and new systems as part of initiatives that are really unrelated to ICD-10, but where we had to get them in because the systems they were using we were not going to be able to remediate.
And so we’re expecting we’re going to get some breathing room and have already planning around what is the impact of a delay, and if we just guess and say it’s going to be, conservatively, 12 months for hospitals and maybe 12 months or maybe 24 months on the physician side, if we just stayed conservative, because I don’t think they’re going to delay it by less than that. I’m not sure if we’ll really accomplish anything if we delay the hospital date by six months or the physician date by six months. So we just took a conservative approach — what does that mean to us? What does that mean to us in terms of our budget for ICD-10? What does it mean to us in terms of the work effort and the way it’s laid out across the timeline, and what does it mean for these other initiatives that were sort of indirectly related to ICD-10? And so we’re doing that planning. We’re finishing that planning really right now, but we’re not going to change anything until that date is formally announced.
I certainly I welcome it, as I think any healthcare CIO would probably say, unless they’re one of the few that were there and done, but I certainly welcome it. I think it’s a challenge for us to deal with all of these things at once, and I think it’s even more of a challenge for smaller and medium-sized places or places that are struggling more than we are financially. We’re in pretty good shape financially as a health system. We’re very large and very diversified and so we have the resources to do these things, whereas a lot of places don’t. And so I think it’s caused a panic in a lot of places to be able to say, ‘We have to invest in these EMRs or we’re going to get penalized, but at the same time we’ve got to spend a lot of money on ICD-10, and we just can’t get it done.’ So I think it’s very welcome news. I think it’s very smart for them to do. I just hope that the dates get announced very shortly and it doesn’t get dragged out, which is my expectation — that it won’t be long before we know the real dates.
Gamble: You bring up a very interesting point about smaller or medium health systems or hospitals versus the larger systems. It’s interesting because they have fewer resources but sometimes they also have fewer projects, so it’s kind of a grass-is-greener type situation to some extent, I think.
Bosco: I think that’s true, and every place is different, and it’s different in other areas of the country. I do talk to a number of CIOs and we certainly have a fair amount of them around here; even in our immediate vicinity, there are 20 hospitals just in the borough of Brooklyn alone, all of which are small to medium-sized places, and there’s a half-dozen or more in Long Island here. So even though New York City is dominated by five or six really large health systems, there is still a fair amount of small ones. And when I talk to those CIOs, they’re a little bit scared because they’re worried about the future of their hospital and the ability of that hospital not only to deal with these investments that need to be made and this transformation that needs to be made, but also, are they going to be able to withstand the impact of value-based purchasing and all of the things that are coming down the pike that are going to really test the ability of some places to survive.
Gamble: Absolutely. I’ve heard it being referred to as a perfect storm, everything CIOs have to deal with right now with the number of projects and priorities. One of the things that we often talk to people about is how they do manage to keep all the balls in the air. From your perspective, do you find yourself kind of relying on your staff more than ever to help keep everything moving?
Bosco: The first thing you have to do is have a positive attitude, and not everyone does. I was with some high level people from IBM who had just been at a conference where there were 35 healthcare CIOs, and they said it was a depressing situation. There were people saying, ‘I didn’t sign up for this,’ ‘I don’t think we’re going to be able to handle this,’ ‘This isn’t fair,’ and all these kinds of things. And that’s a recipe for failure right there. The first thing you have to do is decide that you’re going to work seven days a week, and work very long days for a number of years, because these are the times. We’re in the middle of a major transformation of an industry, and that’s what it takes. These aren’t the times to sit back and be looking to coast toward retirement or hope that you’re going to have a job where you can go out and play golf once in a while. It’s just not that way anymore. You’ve got to have a really very positive attitude and project that out to all of your staff who are also working their tails off and a little bit nervous about how much is going on. So a positive attitude really goes a long way to feel like, ‘I don’t know all the answers. I don’t know exactly how everything is going to unfold, but it’s going to work out, and somehow we’re going to pull through it. We’re going to do a great job and everybody just has to believe that.’
In a big place like this, one of the important aspects of my job is to surround myself with really good people in my department as well as the rest of the health system, and I’m very fortunate that I can do that. Not everybody is in that position and some places just can’t afford it, or the staff isn’t out there or the staff isn’t willing to go to the more challenged places, but I’m very fortunate here. I’ve got six or seven direct reports and every one of them are phenomenal. I wouldn’t want anybody in any one of those positions different than the person that I’ve got there, and that obviously makes a huge difference. Part of my job is to just keep them productive and knock down obstacles for them and keep them focused and keep them believing. They are the ones that crank out all of the work, not me.
It takes a lot, and with the job market as tight as it is, it’s getting harder and harder to recruit talent. You’ve got to develop a reputation, whether it’s locally or beyond that, where your organization is a really a good place to work and you’re very progressive about everything you’re doing. You’re going to be one of the survivors in this whole shake-out and if you come here, there are a lot of good things to do and a lot of ways to get a sense of accomplishment. You’ve got to keep that going so that you can attract good people, because I know of a lot of places that are doing a lot are spending a lot of time looking for people and we are too. We onboarded 140 new people last year and we’ll do at least a hundred this year, and we’ve done that many for the last few years. And so to keep attracting that number of people and assimilate them into the organization and make them feel comfortable and happy to be here takes a lot more effort than it used to be. We pay a lot more attention to talent acquisition and retention nowadays than I ever remember in my career having paid attention to.