Since becoming CIO at Albemarle Health in 2005, Stephen Clark has made great strides in helping to advance the organization. But for facilities based in rural areas, it’s becoming increasingly difficult to compete, which is why Albemarle is turning to Sentara Healthcare to help strengthen its presence in the community. If the deal goes through, it could be a game-changer, says Clark, who offers his thoughts on the challenges of recruiting and retaining staff in a rural area, the importance of transparency, and the telepsychiatry HIE that is setting the gold standard in North Carolina. He also talks about the hurdles to CPOE adoption, his biggest beef with MU, and the pains of dealing with seasonal fluctuations in patient volume.
- CPOE roadblocks — “The technology gets in the way.”
- “At-the-elbow support” from nursing
- Struggling with quality measures
- Stage 2 — “It’s a matter of maturing what we have.”
- Being the resident MU expert
- Telepsychiatry HIE
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This is a game changer for them, and so what we try to do is a little give and take. If you can adopt and change your practice and how you document and how you order, we’ll meet you halfway and try to make the process as easy as we possibly can.
Our biggest challenge was getting CPOE up and running. That was the juice that made the medical staff come to the table and say, ‘we have to do this — not just because of stimulus money, but because it’s the right thing to do.’
With a lot of the other core requirements and the menu items, we’re already out of the gate, so it’s not like we have to buckle up and try to do some new things that we haven’t even planned on doing. It’s just a matter of maturing what we have and being more aligned with the requirements.
The problem I see is what you understand it to be and what ONC is looking for may not be the same two things. A lot of times the rules either get clarified or changed, and that might throw you off a little bit.
A lot of larger organizations have a team of people that are dedicated just to focus on Meaningful Use. I don’t have that luxury. I’ve got to do that work in addition to everything else I do, and that becomes a challenge.
Gamble: More times than not, it tends to be a complex picture. Unless you’re one of the very few systems that owns all of their practices, usually there’s a little bit of juggling that has to go on.
Clark: Well, not just a little bit of juggling. We’ve been positioned to expand and develop a community-based HIE, but it’s going to take an investment to continue to do so. Looking at what’s happening with our tertiary partners that we refer to, they are all on an Epic platform, so the plan for us is to transition at some point to Epic. I don’t know what’s going to happen with the independent practices — that’s yet to be determined. There’s been some discussion that Sentara or Vidant or whoever may decide that they want to acquire those practices. I know that there are some primary care practices that are struggling in our community, and they’ve been talking with both Vidant and with Sentara about a possible acquisition there. Once those practices are acquired, they will go on to an Epic platform.
Gamble: When we talk about practices in the rural setting, from EHR and at CPOE standpoint I can imagine that there are a lot of challenges, not just in terms of cost, but things like computer literacy and network infrastructure. Are those things that have been challenges to deal with, just in terms of getting these practices set up?
Clark: Of course. Our biggest challenge, I think, has been related to CPOE. In fact, we have done a lot of maturity around our EMR, with the exception of CPOE, up until about a year or so ago. Fortunately, because we do have a dedicated hospitalist group, we’ve been able to get some strong adoption around CPOE with the hospitalist group — the entire medical staff that sees patients in the hospital, whether they’re employed, independent, or contracted. We have 100 percent of our physicians using electronic progress notes, which has helped tremendously with handwriting recognition and care plans. The CPOE adoption continues to evolve. We are working on strategies to improve our adoption rates. Overall for the hospital, I would say on average we’re probably in the 55 to 60 percent range. We would like to get to 90 percent CPOE. Our hospitalist group is doing about 85 percent CPOE. Some of the other medicine and surgery groups are at a lower rate — probably around 50 percent.
As we continue to mature, we’re looking at barriers physicians are having. I wouldn’t say computer literacy is a problem per se. I think sometimes the technology gets in the way of how they have traditionally practiced medicine. This is a game changer for them, and so what we try to do is a little give and take. If you can adopt and change your practice and how you document and how you order and that type of thing, we’ll meet you halfway and try to make the process as easy as we possibly can. We’ve done things like single sign-on with proximity badges, and we have a team of clinical nurses that do at-the-elbow support with them when they need it. We look at things that become troublesome or confusing for them and try to streamline the process as much as we possibly can to make it simple for them. It’s an evolving process. Like I said, we’re watching our adoption rates to make sure we don’t backslide, but continue to push forward towards our 90 percent goal.
Gamble: I would imagine the hospitalist group really does play a key role in this.
Clark: They care for the majority of the patients in the hospital, with the exception of OB and surgery and some medicine patients. But the majority of the patients that are seen in the hospital are cared for by the hospitalist group.
Gamble: Right. Now it’s time for the question I can’t stand asking sometimes. In terms of Meaningful Use, where do you stand on that?
Clark: Where do we stand as far as where we are as an organization, or where do I stand personally on it?
Gamble: That’s up to you if you want to talk about that.
Clark: Well, let’s go with the politically correct answer. Surprisingly enough, by the time the Meaningful Use requirements came out, we were probably about 80 percent there. It wasn’t like it was huge leaps and bounds. Our biggest challenge was getting CPOE up and running. That was the juice that made the medical staff come to the table and say, ‘we have to do this — not just because of stimulus money, but because it’s the right thing to do. It’s aligned with patient safety goals.’ And if we don’t get there, there will be disincentives, so this is something we just have to do. Ironically, the hospitalists were ready to go, so it wasn’t like we had to win them over. They were foaming at the mouth, so that was good. We were already well on our way because we had our vision around our community HIE and what we were doing with exchange of information. So a lot of the challenges that many organizations had in achieving Meaningful Use stage 1, we were already there.
Our biggest challenge was around the quality measures, because the way ONC and CMS has outlined that, it’s just not the way the workflow goes in our organization as far as how we capture that data. Typically, we have abstracted that information in the report for core measures. But it did force us to change a lot of practices, and I think out of everything, that was the thing that delayed us from jumping in on the first year of stimulus. We were able to enjoy a second year stimulus on it because we were able to finally crack the quality measures problem. But going forward, it continues to be something that we keep a watchful eye on. As we’re focused on stage 2 and we’re planning to be ready to attest our 90-day period next July, our biggest challenges there are going to be around electronic reporting of the quality measures as well as the adoption of a patient portal. Those will be our two biggest challenges, and I think we’ll be successful. With a lot of the other core requirements and the menu items, we’re already out of the gate on a lot of that, so it’s not like we have to buckle up and try to do some new things that we haven’t even planned on doing. It’s just a matter of maturing what we have and being more aligned with the requirements.
Gamble: It gets very tricky, very hairy. Did you find yourself in contact with other CIOs or other leaders in similar situations or in the area just to talk through things like quality measures and see how they were dealing with the challenges?
Clark: We do. Being, I would say, probably one of the early adopters of attestation in the State of North Carolina, at least for the smaller hospitals and rural hospitals, I’ve had more people calling me and asking, ‘how did you do it? How did you do it?’ It’s a team sport. There’s a lot of dialogue that goes on. I’ve gotten a lot of useful information out of going to the Meditech CIO forums, out of going to CHIME and HIMSS and gathering information from those sources, and from webinars and white papers that we’ve seen coming out from consultants and other thought leaders.
The problem I see with it is what you understand it to be and what ONC is looking for may not be the same two things. A lot of times the rules either get clarified or changed, and that might throw you off a little bit. We’ve had that problem. I know a lot of larger organizations have a team of people that are dedicated just to focus on Meaningful Use. I don’t have that luxury. I’ve got to do that work in addition to everything else I do, and that becomes a challenge to make sure that I keep a pulse of what’s going on and I understand what the requirements are and provide the proper leadership to my team.
Gamble: That’s a huge thing to have on your plate. Without having a dedicated staff or even a dedicated person to that, are there a couple of people or is there one person in the organization you can turn to, or is it just, ‘Okay, I’ll take this on.’
Clark: No, it’s just a matter of where is it going to be best suited, and we just go that way. In addition to the hospital, we have employed physicians. We have several practices out there, and we’ve got to make sure that they’re on track for Meaningful Use as well.
Gamble: That would be a nice thing to have a whole dedicated staff for that.
Clark: Yeah. Some of the things that we’re doing around Meaningful Use as far as feature-function initiatives where we have to hit certain thresholds, we’ve carved those out as projects and we have dedicated people to work on that. But as far as having a core resource who lives and breathes this stuff day in day out and who has the pulse on what’s going on at ONC and with the state Medicaid office and that type of thing, I don’t have that. I’ve got to pick it up as best I can. I think that would be true for probably most other hospitals like us. I can’t see that they have that, unless they’ve been able to contract with a contract firm to come in and actually do their Meaningful Use work for them.
Gamble: Right. And you said the version of Meditech you’re on is stage 2 certified?
Clark: Well, the one that we’re upgrading to is — Meditech 5.6.6. We have the code. We’re vetting it out now, doing our testing and customizations that type of thing to get ready for go-live in September.
Gamble: Okay. So you talked about the community-based HIE, but do you have any involvement in a statewide HIE at this point?
Clark: Oh yeah. Our foundation started a telepsychiatry program about almost three years ago. We started it with help from the Duke Foundation. It was in response to being in a rural community where we just don’t have psychiatrists or other mental health professionals in the community to respond to patients that are in crisis. What happens is a lot of times patients that are in crisis end up acting out. Usually, law enforcement is involved; they come in to our emergency departments and they clog up our EDs.
And so we started a telepsychiatry program where we actually use video conferencing. We have contracted with a psychiatric group in Jacksonville, N.C., which is about three hours from here. They provide seven-day consults via video conferencing. They do it on a per click basis or a per consult basis, and it’s been very successful. We have radically reduced the amount of psychiatric holds in our ED. We are able to cut down a lot of hospitalizations because these patients come in, they get their meds stabilized, and they go home. Before, what happened was they’d say, ‘this is a psych patient — they need psychiatric services,’ and then we would look for an inpatient facility to send them to.
It’s been a very successful project for us. In the first two years, we have about 12 hospitals that came on board with it. We have since added another six hospitals to it this year. It’s been put in legislation to have this program go statewide, so it will no longer be run by our little foundation here in Elizabeth City. It will actually be managed by one of the academic medical centers that have a psychiatric program.
But that program is going statewide, and part of that is an HIE component. I’ve been very active in working with the Department of Health and Human Services and the North Carolina Hospital Association in defining how that HIE should work in order to support the telepsych program.