In the current health system landscape, where organizations just keep growing, Calvert Health System is considered to be quite small. But it’s a “mouse that roars,” according to CIO Ed Grogan, who has spent the past 12 years leading Calvert’s transformation from a small hospital to a dynamic health system. In this interview, he talks about the Maryland eCare initiative and partnerships that have expanded Calvert’s reach and helped improve care for patients across the state. He also discusses the organization’s comprehensive EHR-selection process — and why they ultimately chose Meditech; their work with CRISP, including plans to implement a “Magic button” for physicians; the importance of team chemistry; and his “passion for technology integration.”
- NextGen’s community HIE
- Attesting to MU 2 (acute in 2014, ambulatory in 2015)
- Push & pull methods of data exchange
- CRISP’s magic button to give docs “a broader scale of information.”
- Patient-centered medical homes: “It’s not just high tech; it’s high touch.”
- Maryland eCare
- “We’re the mouse that roars”
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We have different ways of exchanging data. We’ve got the direct method now, which is more of a push, although we are setting up query mechanisms. And then we have the HIE, where providers can consume information on demand. It’s sort of a pull technology.
We also provide care managers. It’s not just high tech; it’s high touch. That’s a very important element.
We’ve been talking about the possibility in the future of having more ambulatory data in CRISP, and perhaps even having some analytics and maybe even some workflow tools for care coordinators and care managers to help with the whole population of health management effort.
I’m certified both in IT and also in clinical engineering, so I’ve enjoyed that project from a perspective of technology and integration.
We took him over to the ICU to take a look at the telemedicine setup since we were the first in Maryland to do that, and he turned to his secretary of health who was with him and said, ‘Why isn’t the University of Maryland doing this?’
Gamble: At this point, you’re exchanging information with both the employed and affiliated practices, and NextGen is primarily being used among the employed physician practices?
Grogan: Let me explain that a little bit further. About 25 percent of the providers using the NextGen platform are employed. The other 75 percent are independent. So we have quite a few independent physicians, one very large practice, and a lot of small practices in the community using it. The Department of Mental Health for the state, the mental health clinic in the county, we’re also hosting for them.
We’ve set parameters regarding information sharing in that area, because it’s a sensitive area. Back in 2010, we established a community health information exchange. We actually acquired the NextGen HIE; they called it CHS (Community Health Solutions) back then, but it’s been rebranded NextGen HIE. And we implemented that back in 2010 to connect the hospital, the physician practices — independent and employed, four imaging centers, and three outpatient labs together, to facilitate not only data exchange, but also data sharing. The physician practices who we serve signed up for the data sharing plan where they basically can consume lab results ordered by other providers in other practices; they can consume a lot of information from the hospital.
And this is back in the day prior to Meaningful Use Stage 1 and Stage 2, prior to the C-CDA, to the HISP, etc. So there was an initiative in the Maryland/DC area—the Maryland/DC Collaborative for Health Information Technology — that was looking at setting up a RHIO, but that never came to fruition. What followed was CRISP, the state of Maryland’s HIE, which is doing very well today, providing excellent service. I’m also serving on the technical advisory board for that organization. That has come to fruition, but we implemented a community HIE before CRISP existed and once the RHIO and the Collaborative for Health IT fell apart. We still have it in place today.
The Chesapeake Regional Information System (CRISP), the state of Maryland’s HIE for our patients, has now a second generation of technology supporting it. They use Mirth as their underlying platform, and so we’ll be replacing the NextGen HIE and community HIE with Mirth HIE. The parent company of NextGen QSI purchased Mirth, and Mirth’s a very solid platform, and so we were actually replacing the NextGen HIE with the Mirth HIE this summer, by August or September at the latest. That’ll give us additional capabilities for better workflow for our providers consuming information, and it provides the opportunity for more synergy with the state HIE, which is also on a Mirth platform, moving forward in the future.
So that’s part of our strategy for information sharing, as well as leveraging Stage 2 Meaningful Use interoperability capabilities, which we’ve implemented and are certainly using today for hospital-to-physician communication information, and then from physician to physician. But we really haven’t optimized use of that technology to its greatest potential, so we’re also working on that optimization. We did achieve Stage 2 Meaningful Use last year for the hospital in 2014, but the physician practices elected to wait till 2015 to achieve Meaningful Use Stage 2, because the CMS offered that flexibility. So the physician practice is a little behind the hospital. Again, we’re still working on optimizing the capabilities of Meaningful Use Stage 2 technology. That’s what we’re doing in the area of interoperability.
Gamble: Okay. I would think that having that in place a couple years put you in a good spot as far as Meaningful Use and not having to start from scratch in having that level of data exchange with the physicians.
Grogan: We have different ways of exchanging data. We’ve got the direct method now, which is more of a push, although we are setting up query mechanisms. And then we have the other form as well, the precursor to that, which we still have in place — the HIE, where providers can consume information on demand. It’s sort of a pull technology where they can consume information. The community HIE does have a clinical data repository. Folks don’t access it through a portal today; they will be able to do it with the new HIE. But they can, within the workflow the ambulatory EHR, pull information from that clinical data repository. Also, information can flow through the HIE from the hospital to those physician practices through that channel as well.
Gamble: You talked about CRISP, which you are involved with. That’s one of the HIEs that we’ve heard really seems to have that secret sauce and really seems to be thriving, which is good to hear. Because in speaking with people all around the country, HIEs certainly can be challenging to keep them going.
Grogan: One of the things we’re doing right now is installing a magic button. We’re starting with the hospital information system. We’re in the middle of working on that project right now; that should be live in a month or two. Providers within the hospital information system — hospitalists or emergency physicians — will be able to click a link within the patient’s chart, and it’ll go directly to that patient’s chart in CRISP in the virtual EHR in the CRISP data repository. So we’ll be able to look at a broader scale of information beyond just our own community, and look at that patient’s medical history from the CRISP database as well. We’re in the process of doing that to make that an easy transition.
CRISP has provided a lot of other value-adds. We were very instrumental in promoting and supporting the creation of patient-centered medical homes in our community, both for our employed providers and our independent primary care practices. By hosting the ambulatory EHR for almost all primary care practices in the county, we helped them achieve Level 3 NCQA status for patient-centered medical homes.
We also provide care managers. It’s not just high tech; it’s high touch. That’s a very important element. And so we have care managers that not only follow up with patients in their homes — we have a post-discharge clinic we’ve established in the hospital for patients with certain chronic conditions — but we also provide care managers on a contractual basis to the independent practices to use in their patient-centered medical homes. They’re alerted when a patient is discharged from the hospital — not only in our hospital and our community, but also other hospitals, tertiary care centers, etc. They’re alerted when the patient is seen in an emergency department or discharged from the hospital — a different hospital outside of our community — so they can quickly react. That’s been a value add.
Plus, CRISP provides the PDMP (prescription drug monitoring program) for the state. Maryland was one of the last states in the country to have that program. And the timing was right, because CRISP was there, so they actually host the PDMP database. That provides a good source of information for our hospitals, primarily emergency physicians for patients who present in the ER who are drug seekers. Having that PDMP program and access with the magic button make it easier to navigate and get that information that will help us in a lot of different areas.
Gamble: Okay. So this is a pretty active HIE as far as being able to come up with different initiatives that obviously there’s a need for.
Grogan: Yeah. And the state is looking at leveraging them even more and more. We’ve been talking about the possibility in the future — we haven’t made a decision on this yet — of having more ambulatory data in CRISP, and perhaps even having some analytics and maybe even some workflow tools for care coordinators and care managers to help with the whole population of health management effort and to help with the health management coordination.
Because, again, the state is regulated. Most hospitals are capped for revenue, and the state of Maryland is trying to maintain its Medicare waiver. In the state of Maryland, we’re an all payers state. All payers pay a similar level — not exactly the same necessarily, but pretty close — for services under rate-regulation. So for example, Medicare pays more for a service in Maryland than it would in another state, and the private payers pay less because there’s not that offset there. But Maryland’s been able to contain the cost curve to keep it below the medical inflation rate for the rest of the country, and because we’ve done that on an experimental basis — and this going back decades — CMS has allowed us to maintain this waiver. We want to maintain the waiver, and in order to help deal with the cost curve and to curtail medical inflation, we’re looking at even leveraging CRISP to help in that effort as well as with the population health management.
We’re doing some things with CRISP right now with the encounter notification service where care coordinators are notified when a patient is discharged to another hospital or has been seen in the ER. And again, we’re looking at even going further with that for population health management and leveraging CRISP to help with that as well.
Gamble: Right. So now in terms of telemedicine, can you just talk a little bit about Maryland eCare and what that program has been able to do?
Grogan: I wrote the feasibility study for Maryland eCare back in 2006 or so. Initially the genesis of that was that there were community hospital CEOs that banded together, and they were looking to solve different problems. One of the problems they were trying to solve was the fact that The Leapfrog Group had made three initial recommendations for leaps to improve quality and one was for 24/7 coverage by intensivists, those who are board certified in critical care medicine, in all ICUs. There aren’t enough board certified intensivists in the nation to adequately cover every single intensive care unit 24/7 in all hospitals throughout the country. So they were trying to figure out a way to address that.
At the time, there were a couple of concepts regarding telemedicine, there were a couple of different models out there. University of Maryland was testing one model, and others around the country were testing other models. There was a technology developed from some physicians out of Hopkins that hadn’t been implemented in Maryland yet but it had been implemented around the country starting in Sentara in 2000. So we looked at that. The Delmarva Foundation and Medicare Quality Improvement Organization was tasked with doing the feasibility study. There was some turnover in the organization. I was tasked with doing it from the IT perspective, but we also had folks who brought medical and quality and nursing perspective. But they had some turnover in the organization, so I ended up quarterbacking the effort. I did engage the Delmarva Foundation on the quality piece, but I wrote the feasibility study for the CEOs, presented to the CEOs of community hospitals in Maryland, and they liked the concept of ICU telemedicine to extend intensivists to more beds than they could possibly cover being physically present.
We ended up looking at a couple of options regarding should we build something in the Baltimore area to serve Maryland, or should we look for another organization that’s an early adopter that maybe would extend to cover some community hospitals in Maryland? So we did a big feasibility analysis. Along with my CEO [at the time] Jim Xinis, who’s recently retired, we went out and met with a lot of different health systems from inside the state and outside the state, and at the end of the day, elected to form an LLC, Maryland eCare, to contract with Christiana Care initially.
We were the first hospital in Calvert to go live with tele-ICU services from Christiana Care. We had that contract with them for five years. We saw significant improvements in our APACHE scores. We saw significant reduction in ICU mortality in the double digit range the first year we went live, and had extreme success with reduced length of stay. What the service provided to six community hospitals today is after-hours support by the remote center for intensivist support. So from 7:00 p.m. to 7:00 a.m. on weeknights and 24 hours on weekends and holidays, we have remote intensivists serving as the attendings of the patient. Now, they’re not replacing the attending. If something critical happens with a patient, they will communicate with the attending. But the attending doesn’t have to take every single call from the nurse after hours, so they can get some sleep. They can have a better lifestyle.
The remote intensivist handles that, but below the remote intensivist at the remote site are our experienced critical care nurses, most of whom are certified, and they also provide monitoring and screening 24/7 even 24 hours a day during the weekdays. The intensivists only come on at night during the weekdays, and of course, they’re there on the weekend. That service has two-way audio/video with the patients and the intensivists. We basically integrate our information systems and our clinical lab results. They have access to our PACS and the electronic health record. We also interface physician notes between the remote intensivist site and the hospital both ways, and we also have integrated physiologic monitoring as well. We have not only vital signs information back at the remote site, but we also have near real-time waveforms, so we bring in the disciplines of clinical engineering or biomedical engineering and IT and telecommunications to make this happen. That’s an area that I particularly enjoy, because I have a background in all three areas actually. I’m certified both in IT and also in clinical engineering, so I’ve kind of enjoyed that project from a perspective of technology and integration.
It’s been very successful. We have six hospitals aboard now. We’ve actually moved that program over to Maryland. We had the governor of Maryland cut the ribbon on a new medical arts center in our county back in 2010. We took him over to the ICU to take a look at the telemedicine setup since we were the first in Maryland to do that, and he turned to his secretary of health who was with him and said, ‘Why isn’t the University of Maryland doing this?’ So we actually engaged in conversations with the University of Maryland medical system and we moved it over to the University of Maryland from Christiana when our five-year contract with Christiana expired in 2013.
Now, the University of Maryland Medical System and its vice president of telemedicine, Dr. Marc Zubrow, who came from Christiana Care, are overseeing this program and looking at expanding it beyond tele-ICU services to also other areas for possibly tele-neurology, tele-psychiatry in the future. They’re developing a strategic plan and a game plan for that. So we’re kind of the mouse that roars, so to speak. Calvert Health started this and now that’s helped spur the University of Maryland Medical System and the state to do more of this ICU telemedicine, which they’ve also extended to their own hospitals at the University of Maryland Medical System — their own community hospitals, and then it can go into other areas as well. So we were very happy about that project.
It has improved patient outcomes, patient quality, and patient safety. I mentioned patient safety earlier. I should also mention that we were also the lowest in the state now with all of our efforts and care management efforts for readmissions; we’re number one and number two in the state for lowest readmissions. We also have the highest survivability rates or the lowest mortality rates now in the state. So we’ve really been focusing on the patient, on quality and outcomes, and we’ve been effective in a lot of things we’ve been doing.