Talk about hitting the ground running. When Lee Powe started as CIO at Hugh Chatham Memorial Hospital, he had just five days to familiarize himself with his new surroundings before kicking off a major system installation. Fortunately, it was the same ED system he had implemented at his previous organization. But still, it gave him a taste of how much work needed to be done — and how different it would be to lead a smaller organization. In this interview, Powe talks about the risks and benefits of using cutting-edge technology, Hugh Chatham’s approach to data exchange, the importance of having a true open-door policy, why it’s impossible to keep everyone happy, and what keeps him up at night.
Chapter 2
- Patchwork HIE
- Data ownership issues — “It’s supposed to be about the patient.”
- Teleneurology with on-call specialists
- Tracking readmission data
- Dealing with “the Burger King mentality — “It’s easy to turn into a best-of-breed.”
- Preparing for RAC audits
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You get into issues with ownership. Even though healthcare is supposed to be about the patient, you’re still marketing to try to get them to come to your facility. So for larger facilities to want to share data, I think it becomes a challenge.
You have to make sure you’re tracking the right metrics when it comes to telemedicine. Where is the report coming from? Who is paying that person? How are we tracking this? What are our results? You need to put a good process in place.
To be honest, I don’t think healthcare is slowing down. I think it’s picking up. As much as you want to hold everything together to a single-source vendor it’s really challenging to do it, because all your major components in the facility have the Burger King mentality — they want to have it their way.
It’s like selling a car. The more cars you sell, the more money you get. Well, the more accounts that they audit that don’t get challenged, the more money they get paid. It’s going to crush and hurt a lot of small facilities.
We’ve actually hired a nurse to be in charge of that program. We don’t have a whole lot of choice. To remain afloat, you have to put the resources in it to stop the bleeding.
Gamble: I’m not sure what the picture looks like in your part of North Carolina. Obviously, you’re right near Virginia too, but in terms of health information exchange, are you doing anything in that area?
Powe: It’s funny because in western North Carolina they have a health exchange, and in eastern North Carolina they have a health exchange. I’m in central North Carolina, and we don’t really have a health exchange here. I’m actually working with one of the large facilities in Winston and I’ve asked that question: how can I exchange data with you? I don’t necessarily want anything in return, because my patients are going to go to them when they need to be transferred from trauma care, so I’d rather the record beat the patient there. They are actually working with me right now so that we can have some type of exchange, at least between ourselves so that we can get them the data. So no, we’re not there yet, but yes, we would love to exchange data with someone. But it’s got to have a meaningful purpose behind it. We just don’t want to put the data out there to have something to do. We want to send it to the facilities that we’re going to send our patients to, to help the patient.
Gamble: Which organization were you speaking with?
Powe: We’re actually speaking with Novant Health Forsyth Medical Center in Winston‑Salem.
Gamble: It seems like it gets kind of tricky with the health information exchanges, especially since you’d have to either decide whether you hook into western North Carolina or eastern North Carolina, and then you’re so close to Virginia as well. It doesn’t really make sense to do this unless it’s something that’s really going to help the patients that you serve.
Powe: Right in our area, the facilities are all comparable in size. So if you go to the west of us about 30 miles there’s a facility about the same size, and if you go north of us about 30 miles is a facility the same size. For the most part, all the facilities even up into Virginia are all about the same size, so they are all sending their patients to the same facilities to the east of us. I will probably never send anybody to the west; I will always send them to the east. I want the record to beat the patient to your emergency department. That’s all I want to do — to make sure the data is there, they know what’s happening, and they know what’s coming.
Gamble: It’s an interesting situation in a lot of states with HIEs because there is a lot of hesitancy. It’s a model that a lot of people have trouble with, and you can see why from a sustainability standpoint.
Powe: I believe that you get into issues with ownership. Even though healthcare is supposed to be about the patient, you’re still marketing to try to get them to come to your facility. So for larger facilities to want to share data, I think it becomes a challenge. I really believe North Carolina Hospital Association has done a tremendous job. I wish they could expand it out more. We submit our emergency data through the state as a requirement. Every hospital sends the data to a program called NCES (North Carolina Emergency Services), and I believe the CDC is using about 16 percent of North Carolina because we all submit all of our emergency data. If we could get the proper funding maybe for the hospital association to get more data, we could create our own North Carolina Health Exchange sponsored by North Carolina. I think that’s the way that we can get everybody playing together well.
Gamble: It’s such a tricky issue. From our standpoint we speak to CIOs in a lot of different states and it’s interesting because there are so many different models and everyone’s just trying to find the right formula that works, but each area has different needs. It’s a tough situation.
Powe: Yeah, that one is going to probably have to be more state-driven or government‑driven, I believe, to make it totally successful.
Gamble: Now you’re in a pretty rural area. Do you have any plans to do any kind of telemedicine work or are you doing anything in that area at this point?
Powe: We actually do telemedicine right now. We do teleneurology because we’re a stroke center. We have neurologists that are specialists on call that are actually coming through the system and doing everything for us. We also have telepsychiatry to help us because we all have some mental health issues throughout healthcare. Once you get a patient in, until you get somebody that can actually start helping the patient, you can never get them out of your facility. So that is doing some wonders for us so yeah, we are doing it.
Gamble: That ties into the whole readmission issue and making sure those patients still have care but aren’t necessarily being admitted to the hospital again and again.
Powe: That’s a tough one when you get into readmissions. We have so many applications that are trying to monitor for readmissions and how to deal with readmissions. There are so many big vendors around us that are in that business right now. So we’re feeding data to health departments. We’re feeding data to free clinics. We’re feeding data to a lot of places trying to help. And with our home health agency, we’re trying to do a lot of monitoring in the home and a lot of education in the home to try to keep from having those readmissions.
Gamble: Is that something where you have plans to expand out to do more telemedicine work? I’m sure it always comes down to funding, but also making sure that you’re able to get the results that you want and really be able to demonstrate some results.
Powe: We’re trying to see where our return is on it. We understand what it is, but you have to make sure you’re tracking the right metrics when it comes to telemedicine. Where is the report coming from? Who is paying that person? How are we tracking this? What are our results? You need to put a good process in place to determine what you’re going to track and how you’re going to tell if it’s going to be successful or not. We’ve done a pretty good job with that. The Duke Endowment has been fabulous for North and South Carolina. We get a lot of grants from them that help us to be successful in these little projects, especially being rural. It helps us to find a lot of these but we also have to pay our fair share too.
Gamble: So obviously there’s a lot going on; a lot of balls in the air. As far as what you’re looking at in the next year or so, are there any major projects on your radar, or is it a lot maintaining and things like that?
Powe: We have a lot of major projects. To be honest, I don’t think healthcare is slowing down. I think it’s picking up. As much as you want to hold everything together to a single-source vendor it’s really challenging to do it, because all your major components in the facility have the Burger King mentality — they want to have it their way. It makes things easier for them, so they want it their way. We’re looking at varieties of software applications for the OR. The lab just changed and pulled out and went with the new system, Orchard. Our ED is already on a different system, so we’re putting in an anesthesia module. We’re looking at that, and case management is installing Allscripts. So you can see it’s easy to turn to a best of breed real fast. We’re trying to make sure that it’s the best tools but then we had to come back and do the interfacing.
Fortunately, we have a very gifted interface engine, Corepoint, but you still have to have somebody on the back end making sure all that magic works pretty well. I think the biggest thing for me coming up and the things that keep me awake at night — and I don’t know what everybody else is saying, but for me, it’s RACs (recovery audit contractors.) What a concept. That hurts. I get that sometimes you don’t always do the proper admission, but companies that are recovering money for the government for Medicare and now Medicaid, because North Carolina, they just started getting hit with Medicaid audits — they get the money. The government pays you for your reimbursement for Medicare. The recovery auditor checks things. We get three letters with 30 or 40 counts on it, and you get tied up. You get a million dollars tied up. What do you think the profit margin of a small community hospital is over a year? They just took that all back from you.
So we have to focus our efforts to make sure we’re doing the proper education, we’re meeting the proper medical necessity, and we’re tracking these things, because they get paid a percentage of money that they recover. That’s called pay for performance. And with pay for performance, you tend to do better. It’s like selling a car. The more cars you sell, the more money you get. Well, the more accounts that they audit that don’t get challenged, the more money they get paid. It’s going to crush and hurt a lot of small facilities. And I’m sure it’s hurting the large facilities too because if I’m giving up a million and a half, then what are the big facilities giving up?
Gamble: Yeah. Do you have a specific committee or a person who’s focused on this or is it something where you can’t really afford to have an entire staff person or group just looking at the RACs? Because like you said, there are so many other things that need everyone’s attention and time.
Powe: We actually have created a new position just for this, because it’s just a business sense. When you’re giving up your actual reimbursement amount, which is three quarters of a million dollars, you have to have somebody to focus on it — and more than one person. Our case management staff is putting Allscripts in, and it’s going to have some tools in it. We’ve put in some Midas software, which is going to have some tools in it, and we’ve actually hired a nurse to be in charge of that program. We don’t have a whole lot of choice. To remain afloat, you have to put the resources in it to stop the bleeding. Your readmissions, if you think about and you do your percentages of what your readmission penalties are, it is a lot lower than what these RACs are taking from people.
Gamble: When it’s a model where they’re motivated to find the errors or to find the overpayments, it puts hospitals in a really tough position.
Powe: Pretty much, yeah. And like I said, pay for performance is an interesting concept. They pay us and then they take it back.
Gamble: And the more Medicare or Medicaid patients you have, the bigger the concern this is, I would imagine.
Powe: If you check with most of the facilities, I would say that a good chunk of them probably have between 50 and 60 percent government insurance —Medicare or Medicaid. That’s the majority of the people that are coming.
Gamble: I can see how you said that that’s the kind of thing that keeps you up at night. That’s pretty understandable.
Powe: You can’t keep giving all your money back and stay afloat, so it does weigh on you a lot.
Chapter 3 Coming Soon…
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