Bill Neil, VP & CIO, Indian River Medical Center, Chapter 1

Timing really is everything. When Bill Neil started as CIO at Indian River Medical Center in early 2011, his first order of business was to create a roadmap for the organization to become completely electronic. But just as they were get started to implement McKesson Horizon, the announcement came that changed everything. Neil and his team decided to take a leap of faith and go with Paragon, and it’s a decision he’s never regretted. In this interview, he talks about what it was like to hit the ground running as IRMC’s first CIO, the challenges he faces in managing a patient population that fluctuates by season and is heavily Medicare/Medicaid, what his team is doing to cut costs, and his advice for new CIOs.

Chapter 1

• About Indian River
• Seasonal volumes & heavy Medicare/Medicaid population
• Strategically scheduling IT projects
• Rolling out an EHR roadmap
• eClinicalWorks in practices & urgent care clinics
• Going with Paragon — “We made that leap of faith”
• “Infrequent admitters”

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Part of the challenge too with us, because we are seasonal, is that we don’t necessarily contract for all the nursing staff throughout the whole 12 months.

There were so many costs we’d already sunk into the McKesson products, and we had a good relationship with McKesson and still do, so we chose to go down the McKesson path for our electronic health record for our hospital side of the business.

For them to make that change at that point, especially with the MU timeframes, it would have been tough. For us, we had a narrow window to make that decision and move forward in order for us to get the stage 1 MU dollars, which we have attested for.

With the total cost of ownership, it was going to save us over $3 million plus over a 5-year timeframe, and so we knew from a cost perspective as well that was the right solution for us.

When they only admit a patient once a month or whatever that number is, that becomes more of a challenge, because even though they’re trained, 30 days later they just don’t remember exactly how to do something.

Gamble:  Hi Bill, thank you so much for taking the time to join us today.

Neil:  You’re very welcome, Kate.

Gamble:  To start off, why don’t you give us a little bit of background information about Indian River — bed size, where you’re located, things like that.

Neil:  Sure, I’d be happy to.  Indian RiverMedicalCenter is located in Vero Beach, Florida. We’re a 339-bed community hospital. There’s only one other hospital in Indian River County and that’s 10 miles north of us. We have 73 employed physicians. Some of those physicians are hospitalists, and the others are employed physicians in our primary care practice groups ranging anywhere from cardiology to intensivists, to family medicine, GI, and so forth. We have two urgent care centers.

We are a hospital that has no debt, and we’re very fortunate for that. We paid off our debt probably about five or six years ago. We are also blessed with a huge foundation that works with our local community members on the island. They do a lot of major donations for us. We raised recently about $50 million through a program that we established and that provided us with a brand new PACU and a SICU, as well as an outpatient pavilion. Our new campaign is for cancer. We are very blessed to have two families that each gave $12 million to the $40 million campaign. Right now, we’re up to about $31 million in about an 8-month timeframe. So we’ve done very well through philanthropy.

We are a seasonal community here, and we are heavy Medicare/Medicaid. During seasons, we flex down as far as staffing in our variable departments such as nursing, and we actually close different units. We are that seasonal retirement, second-home community here in Vero Beach, Florida, just about an hour and 15 minutes east of Orlando. We are north of Fort Lauderdale and south of Cape Kennedy or Titusville, to give you a general location. We are located on the coast, on the ocean — not necessarily the hospital, but the community itself. Hopefully that gives you a background of what we are and who we are and where we’re located.

Gamble:  Right. You mentioned having employed physicians. Do you also have affiliated practices?

Neil:  We do. We have about 200 affiliated physicians that are on staff. There are a number of practices in the community that are credentialed in our system. So between the two numbers, we have about 270-plus physicians that are credentialed and on-staff here.

Gamble:  You mentioned having seasonal residents. Does it present challenges in terms of staffing or is it something where it’s regular enough that you know the months that you’re going to need more staff? Is that a difficult thing from a leadership standpoint?

Neil:  We budget accordingly based on patient days and admissions. Sometimes it is somewhat of a challenge. Depending on the weather patterns, people will either stay here longer or leave a little earlier and head back north, whether it’s the Hamptons or Maine or wherever they go. Sometimes it does pose challenges for us, but we’re getting pretty good at that. When we have those challenges, based on our patient volumes, we do flex down. With our nursing to patient ratios, we’ll flex down and send nurses home. Part of the challenge too with us, because we are seasonal, is that we don’t necessarily contract for all the nursing staff throughout the whole 12 months.

Gamble:  When you’re talking about seasonal volumes, this being October, are you pretty much getting more to that full-staff mode?

Neil:  Yes, we are actually. We start seeing them pick up in October, and we see people leave around the end of March or sometimes the first of April. And so our volumes are picking up. We do have a very active emergency department as well for a community hospital; we see probably around 57,000 visits a year into our ED. Like I said earlier, we’re a very heavy Medicare/Medicaid and have some indigent population as well. I think those pose more challenges to us than anything else.

Gamble:  During those summer months, if at all possible, would you try to schedule any kind of IT upgrades or implementations, things like that, during the time where it’s a little quieter, or does it not necessarily work that way?

Neil:  We do try to do that when possible, because there is a smaller amount of staff and less volume, and so it’s easier for us to do that during those times. Sometimes it’s not always possible, whether it’s a patch release that we need to get in for patient safety reasons, or sometimes because of our project timeframes we need to get something in, for example, stage 1 or stage 2 Meaningful Use. But we do try to do that around the lower season areas of our months.

Gamble:  Let’s talk about the clinical application environment. Now just to set the stage a little bit, when did you start as CIO in Indian River?

Neil:  I started back in February of 2011. I’ve been here approximately about two and a half years.

Gamble:  What was the clinical application environment at that point?

Neil:  We were mixed environment. We were not totally electronic. We had electronic nursing documentation in the hospital. We had automated solutions for radiology, pharmacy — all the ancillary areas themselves. We did have electronic medical record in place in the sense that for our medical record department, we used a product from McKesson. Our physician practices were on a mixture of different systems.

When I first came here, I put a strategy in place to first bring all our physician practices up on one centralized system, and then also to start rolling out that road map for us to bring up a totally electronic environment into our hospital itself. The first thing we did was we brought in eClinicalWorks, and that is what we use today for all our physician practices and our two urgent cares. As we were buying more practices the same time we were implementing, it became a challenge, because we’d buy another practice that made sense for us, and at the same time we’d start rolling them in and bringing them in to the fold of a centralized solution on eClinicalWorks.

So once we had that pretty much in place and it was pretty stable, we focused on the hospital environment itself. McKesson has been a partner here on the hospital side for about 15 years, maybe more. There were so many costs we’d already sunk into the McKesson products, and we had a good relationship with McKesson and still do, so we chose to go down the McKesson path for our electronic health record for our hospital side of the business.

Now we did make a change, probably around the end of 2011, because we were going down with their Horizon suite of products. They came out with their Better Health 2020 announcement, which told us that Paragon was the solution going forward for them. And so we chose then at that point to make that change as opposed to upgrading the systems we had and also adding new functionality like CPOE, medication barcode scanning, and so forth. We decided to make that leap of faith and go with the Paragon product at that point. And that’s what we went live with this past May.

Gamble:  I imagine that that was a tough decision. Like you said, it did involve a leap of faith. Some of the CIOs we’ve spoken to had gone the other way because of that uncertainty, but then in staying with Horizon, some of them are now facing the task of having to migrate to Paragon. In hindsight, it must feel pretty good to know that you did end up doing the right thing in going with Paragon.

Neil:  Yes. When we started that whole transition, we had a lot of conversations with some of the other hospitals in South Florida, and some of those have already gone down the Horizon path where they had CPOE up and running. So for them to make that change at that point, especially with the Meaningful Use timeframes, it would have been tough. For us, we had a narrow window to make that decision and move forward in order for us to get the stage 1 Meaningful Use dollars, which we have attested for.

But Paragon has worked out pretty well for us. We have some challenges around physician adoption and physician training, just like everyone else has, but so far it’s worked out very well. We did put a total cost of ownership together to start out this project. We felt that with that total cost of ownership, it was going to save us over $3 million plus over a 5-year timeframe, and so we knew from a cost perspective as well that was the right solution for us.

Gamble:  In terms of some of the challenges you’ve faced, like physician adoption and training, do you have physician leaders who are taking the lead on this? How are you dealing with those challenges?

Neil:  We do have physician leaders. Again, we’re fortunate because the hospitalists are employed physicians, so they represent probably about 67 percent of the admissions, as far as attending to them. The challenges that we really have are what I call the ‘infrequent admitters.’ Of the 270-some staff that is credentialed, we do have a number of them that do not admit that frequently. So when they only admit a patient once a month or whatever that number is, that becomes more of a challenge, because even though they’re trained, 30 days later they just don’t remember exactly how to do something. That’s more of our challenge right now.

We do have some strong physician leaders that are in place. We have a CMIO. We have physician champions at our hospitalists group, and we use our hospital staff physician champions. At the same time, I have a good clinical informatics group that also helps out physicians. We have one person in our medical staff who does the credentialing of the physicians, and she’ll also do the initial onboarding of a brand new physician, especially if we have to bring in locums, if you will. The other staff that are clinical informaticists have physicians that will schedule appointments with them saying, ‘Hey, I have a patient. Can you I meet Monday morning 7 a.m.? Can you help me through this?’ And we provide that kind of access and that kind of support for these physicians.

Gamble:  I imagine that’s key when you said you have physicians that aren’t admitting that often, because you can give really great training but if it’s a month later, it’s only human nature to not retain all of that information and need a little bit of assistance.

Neil:  That is correct, yes.

Chapter 2