For years, Massachusetts has stayed ahead of the curve in terms of IT adoption. But when it comes to data exchange, even the Bay State has had its share of challenges — both with the sustainability piece, and with what Joel Vengco considers to be a bigger obstacle: politics. In this interview, the first-year CIO talks about the work his organization is doing with the Massachusetts HIE Highway and the Pioneer Valley Information Exchange, how Baystate is positioning itself for ACOs using elements already in place, why transparency and trust are critical to HIE success, and why sometimes it’s better to bite off a small piece of a project than to try to boil the ocean. He also discusses being a Cerner customer in an Epic world, the steep costs of a rip-and-replace, and the key role end-users play in clinical IT success.
- Baystate’s core clinical environment (Cerner)
- “We’re a hybrid of best-of-cluster, best-of-breed, and an enterprise monolithic system.”
- Strong inpatient, ambulatory challenges
- The costs of a rip and replace
- The end-users innovation role — knowledge, insight & mobility
- Taking a page from the travel industry
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I don’t necessarily have to implement another EHR or look to start to put in some basic technology. The foundation is there. We just need to make sure it’s performant, that it has all the right workflows, and that it’s reliable.
Everybody believes it’s the best system. But the question is, can that distant number two be good enough and can it be made good enough with some work. And I think the answer is still yet to be proven, but there’s certainly good reason to believe that it can be.
It’s a huge capital investment to put in a new EHR, let alone rip one out. So then you’re putting at risk even things like bricks and mortar that you’re trying to develop in parts of the region, or creating partnerships. All of those require capital investment, and those dollars will get diverted into this EHR.
How do you create that metaphor of the App Store where you’ve got a very good, curated platform, but you’re enabling folks to really create their own ways of accessing the data and developing workflows that are relevant to them, without putting at risk the data.
When I think about my steps toward innovation and our strategic path for IT, I think about let’s optimize the foundational technology first and let’s make sure people can at least use the legacy systems. Then let’s start to go toward the idea of how do we get to knowledge and insight.
Guerra: Let’s talk a little bit about your core. We can focus on clinical application environment and just get a little more of an overview of your health system from that point of view.
Vengco: One of the things I must say I was very impressed with Baystate when I had first started interviewing for the position was how digitized the enterprise was and is. It’s a Most Wired hospital. It’s Stage 6 HIMSS — almost stage 7, along with other nice accolades that we’ve had in terms of quality awards from Thomson Reuters, which actually now is Truven Health Analytics, for the Top 50 and Top 100 hospitals in the country.
There’s a really great baseline foundational infrastructure and core strategies built for this health system that are really pushing it forward into the next realm of health care, and the technology is certainly a large part of that. We’re an enterprise Cerner shop, but we’ve also got a bunch of departmental systems that are peppered around the health system. I’d say we’re a hybrid of best-of-cluster, best-of-breed, and an enterprise monolithic system.
There are pluses and minuses to that, but our focus right now is to really get to what I envision as three phases. We’ve completed in large part the deployment phase of the technology, and that was really the first generation of IT quite honestly. I was really pleased when I took the interview that they were already past that implementation phase in large part. There are still things we need to do — lots of things, actually, that we’re going to do in this first year to prepare ourselves for the next phase, but I don’t necessarily have to implement another EHR or look to start to put in some basic technology. The foundation is there. We just need to make sure it’s performant, that it has all the right workflows, and that it’s reliable.
There’s a lot of stuff that we need to look to do on the optimization front for the ambulatory part of Cerner. Quite honestly, it’s a fairly decent inpatient or acute EMR, but the ambulatory docs are just beside themselves in terms of the use of it, and that’s because of the way that Cerner grew up. They grew up in the inpatient setting and they tried to apply it to the outpatient setting, and I think they’re seeing the impact of trying to force a workflow that was naturally more acute than ambulatory. Because of the way where ACOs are going, we have to really focus on the ambulatory and transitions of care setting. That’s where we’re going to focus our optimization of the foundational technology.
Guerra: We’re talking about 60 practices that are owned or affiliated — I’m not sure. Maybe you can tell me that. But give me a better idea of the uptick for Cerner Ambulatory among your practices. You talked about optimizing — do you think you can get this to work?
Vengco: I’d say we’ve got roughly 99 percent adoption, if not more. It’s pretty much pervasively used across the enterprise. For those that are owned physicians in our community hospitals and our medical groups, they all use Cerner, but then of course there are bunch of other partners around that aren’t using Cerner and they’re using their own and that’s why PVIX exists. There is, I’d say, a fairly good or actually excellent adoption of the system. But in terms of achieving that optimization, we’re really in the throes of that now.
Of course, coming on as the new CIO, I expected that people were going to ask me, ‘should we go Epic? Everybody else seems to be going Epic. What should we be doing? Should we focus on that?’ So I brought in a third-party consulting firm to be objective about whether or not it was reasonable to think that Cerner could be uplifted or optimized in the ambulatory setting. The study came back and said there are success stories out there showing that Cerner Ambulatory can be made optimized and can actually work in the ambulatory setting.
Now, it may not be as great or as seemingly great as Epic — at least that’s the folklore. I think everybody believes that’s certainly the best system. But the question is, can that distant number two be good enough and can it be made good enough with some work. And I think the answer is still yet to be proven, but there’s certainly good reason to believe that it can be, given there are some success stories out there today.
I think if we decided to consider otherwise and think about a large investment in ripping out the enterprise EHR that we have and putting a new one in, a lot of the other steps that we see in front of us to get to real innovation and to really sustain this new model of care that we’re trying to get to with regard to patient centeredness — those are going to have to be put to the wayside, because it’s a huge capital investment to put in a new EHR, let alone rip one out. So then you’re putting at risk even things like bricks and mortar that you’re trying to develop in parts of the region, or creating partnerships. All of those require capital investment, and those dollars will get diverted into this EHR that you’re doing again for what would have been Baystate’s third time because Cerner was a second EHR. Prior to Cerner they were actually on Alltel but it was PDS which was bought up by Eclipsys back in the early 2000s. That’s how we’re working it out. We’re going to look to put our bet on Cerner but we are, of course, being cautious and we’re measuring every bit of it to see if it’s truly going the direction that we want.
Guerra: You mentioned two different numbers or two different concepts: one was implementation or adoption, and I think you said you had about 99 percent adoption. But then we’re talking about optimization which sounds like it’s a much different number. Let’s try and do this. You’re talking about 99 percent of the owned physicians have adopted the system. What number could you put on those that have optimized it to the point that they are satisfied?
Vengco: That’s a great question. I don’t know if I can give you a percentage, but I can give you a rough estimate.
Guerra: Anything. I’m just trying to understand.
Vengco: So let me just clarify that. Optimization, if you focus on it, is really about workflow and the usability of the system. They have the features that they need; at the very least the basic features. We’ve achieved Meaningful Use and obviously Cerner is certified, but I think we need a lot of work on the optimization of the workflows for those physicians.
On a Likert Scale of 5, it’s roughly a 2.5 to maybe close to 3 in terms of satisfaction of the system by ambulatory docs. So it’s not a big satisfier right now. And EHRs — I don’t know if they can be satisfiers, quite honestly. I think there’s a huge lag in the workflow and usability of any EHR, and I’ve seen all of them. There’s just a huge disparity still in the way that they flow.
At some point I think there’s innovation that has to be let loose, and the innovation is going to come from the clinicians; from the folks that are in the field. The question for CIOs and for IT departments is how do you actually create that capability of innovation? It’s an overused paradigm or analogy, but how do you create that kind of metaphor of the App Store where you’ve got a very good, curated platform, let’s say, but you’re enabling folks to really create their own ways of accessing the data and developing workflows that are relevant to them, without putting at risk the data or putting at risk the maintenance and efforts of operations.
I think that will be a tough design and I think that’s a fun thing to think about in the future, especially with the next generation after us, if you think about how technologically-savvy they are. I believe they can pretty much figure out how to create apps on their own and on the fly and for any mobile device, because they’re going to want to be tethered in the future. They’re going to want to be mobile. They’re going to want to be able to get pieces of functions in real time and that’s really something that we need to look toward as we look to the future.
Guerra: But the current systems — Cerner and Epic — are not designed that way, correct? They’re not designed for a lot of user customization.
Vengco: That’s right. And that’s the real conundrum, I think. But if you take a page out of the airline industry and how today, when you think about wanting to set up a flight, you go to Kayak or you go to Expedia or Trip Advisor and those flight applications or self-service flight applications are actually aggregations of the old Green Screen apps that still exist. And so the legacy systems are still in the background; they haven’t been ripped and replaced necessarily. They’re still there feeding Delta and feeding US Air. But these aggregators are aggregating their information; that data, and serving up new ways of looking at that information, and new functions and features to enable you to compare prices, to enable you to bid, and to enable you to get alerts when something’s gone down, which is great. On Kayak, there’s this one feature where you go in there and you look into the price and you’re just not sure if it’s low enough or if it’s going to get lower or higher. They’ve got this really cool trend and it says, ‘It’s the lowest bid for the last five weeks. You’d better buy it.’ Those are the kinds of things that I think we can certainly do potentially in health care.
And so when I think about my steps toward innovation and our strategic path for IT, I think about let’s optimize the foundational technology first and let’s make sure people can at least use the legacy systems. Then let’s start to go toward the idea of how do we get to knowledge and insight; that’s all about health information exchange and aggregation and analytics and what I’m calling the Center for Analytics here at Baystate. It’s about really getting access to that information easily; transforming the data and making into information and really getting access to that information where it’s real-time and easy and you don’t have to be precluded by the legacy systems.
There’s basically a layer of access, and that layer of access I think will get us towards this innovation that we’re talking about. And so you create a layer of accessibility that perhaps these types of innovation and these new aggregations and views of this data with functions and features can actually utilize. So you get to that Kayak model where the future is not me going up against an Epic monolithic system or a Cerner monolithic system; but I’m taking portions of it, whether it’s a slice of Cerner or it’s a piece of Cerner that I decided to tweak in my own way, and I’ve coordinated or compiled it with another feature and it’s come up with some neat new service or function. That’s a futuristic vision, I suppose, but it’s something that we need to think about, because the paradigm of workflow is changing drastically and dramatically. And there’s no way that any CIO or IT division is going to continue to catch up with the desires of the workforce, because it’s really impossible with all of the changes in health care. The fluidity of health care requires the fluidity of the workflow and the technology to go with it.