Sometimes, a quick glace is all you need. And then other times, it only gives part of the story. That’s precisely the case with Citizens Memorial, which appears to be an 86-bed rural facility, but in reality is an integrated health network that includes 650 long-term beds and a growing base of clinics. It was also the first rural health system to achieve HIMSS Stage 7, and one of the first small systems to achieve MU Stage 2. So when Denni McColm says her organization has been “ahead of the curve in many areas,” she’s actually being modest. In this interview, she talks about what it takes to foster innovation (particularly on a small budget), the organization’s journey with Meditech (and why they aren’t rushing to implement 6.1), what it’s meant to have the same CEO throughout her long tenure, and why Citizens feels like home.
- Medical homes for chronic disease patients
- Data extraction with DVRS
- “At-the-elbow” behavioral health support
- HealthVault’s “untethered PHR”
- Key to remaining independent? “Continued growth.”
- Hosting Meditech for small hospitals
- Innovation on a small budget — “We’ve had to stretch our dollars.”
LISTEN NOW USING THE PLAYER BELOW OR CLICK HERE TO SUBSCRIBE TO OUR iTUNES PODCAST FEED
We have found with MU that we sort of goad people in to signing up because we need them to sign up for our numbers, and so not as many of them are active users. Whereas almost everyone was an active user in 2009, now about a third of the people that sign up actually use it.
One thing I hope we can do in utilizing the portal is to normalize all that data so that the provider can actually use it as they’re caring for the patient in an efficient way, and not have five different places they have to go.
Staying on that vision has been big. For us, because we expanded out and we’re sort of diversified by having all these lines of service, that served us well over the years. If they cut one area, usually we have some other areas where we can make up for that.
We obviously don’t have those kind of resources. It’s almost the opposite — it’s because we’ve had to stretch our dollars that we’ve been able to innovate and make things work that maybe others wouldn’t think to make work.
McColm: One of the things our CEO is extremely visionary about is having a good partnership with the physicians. So really, people in the community don’t know whether they’re employed or independent — we all work together so well and have over the years that people can’t tell the difference.
Gamble: That’s definitely what you want. Now, with such a reach out into the community, what are you looking at with population health? Is that something you’re doing right now or are you looking at in the next couple of years?
McColm: Well, we are not large enough to be an ACO by ourselves. We’ve looked at a couple of models where we would join with others to be an ACO and really haven’t had any good reason to do that. What we have done is establish a medical home program. We’ve got all of our rural health clinics, which is I think 13 clinics, certified as medical homes and we’ve started working with the chronic care populations, the diabetic populations, congestive heart failure, heart disease — all kinds of cardiovascular disease patients. We have software that does extraction from our Meditech system to do quality measures and care management. It’s called DRVS, and it’s been very helpful for us in creating a registry of those various patients. We have health maintenance already built into our EMR as well, so it’s right in front of the provider if the patient needs their preventative or their diabetic care.
And then that same group at the medical home does follow up with every acute discharge from the hospital, regardless of whether they fall into any special population, to see if they have post-discharge needs. So that’s a really nice service that they do to make sure they get to their next level of care, whether it’s primary care or wherever that is. They do another thing that’s nice for population health — when a patient, no matter what, gets a new diagnosis that’s something significant, we have a behavioral health specialist that can be right at the elbows of the provider and meet with that patient and start to take care of any other needs. For example, if you get a new diagnosis of diabetes, that can be overwhelming. And so that behavioral health specialist can help people work through that and help them get on the right track of what services you need that we have so we can help you get through this together — do you belong in one of our panels and how can we help? So we’re doing some things. As far as when we’ll have things like ACO and bundled payments, we’ll see. We haven’t been faced with that yet.
Gamble: That’s really interesting about the medical program. It’s a term that we heard more a couple of years ago and now seems to be coming back because it makes more sense for a lot of organizations. And it really speaks to what the goal of so much of this in having that portable or medical home in the cloud.
McColm: Right. And somebody that’s looking after populations of patients that have special needs especially — mostly it is focused on those with chronic care needs. Medicare, Medicaid and even other insurance companies are paying us to do it, to manage those patients for them.
Gamble: And looking at patients, you have a portal in place on the hospital side and ambulatory side, correct?
McColm: We do actually. We actually put a portal in place mostly on the ambulatory side in 2009, way before it was a requirement, so we were positioned really well. And we upgraded it to add the hospital component — discharge summary and the emergency department discharge record, etc. We already had secure messaging. It’s well integrated with the EMR, so it’s just another task on the provider’s task list when they get a secure message. So I think it was 2009 we did our first. And so at first, everybody that signed up was interested and used it. We have found with Meaningful Use that we sort of goad people in to signing up because we need them to sign up for our numbers, and so not as many of them are active users now. Whereas almost everyone was an active user in 2009, now about a third of the people that sign up actually use it, which is probably about right anyway.
We also are hooked up with Microsoft HealthVault. It’s what we call an untethered personal health record. If a patient signs up for Microsoft HealthVault, they can hook up their Fitbit and their blood pressure machine and their glucometer and all kinds of other little apps. And then they can also request that we send like records, so if they have a new blood results or a new program or new allergy or new medication, it will flow over to Microsoft HealthVault and populate their personnel health record as well. We don’t have as many people using that, but we have a few hundreds that are pretty active users for that service as well.
Gamble: In terms of patient-entered data with wearables, do you anticipate being able to do something with that?
McColm: We do. The vendors are really starting to talk about it now. Over the years, there have been two or three different sort of vendors who have offerings where they could enter their pre-visit information. I’m on an advisory group or focus group with Meditech to talk about how patient-entered data like blood pressures and that sort of thing should be utilized in the system. We actually already do it for our home care patients — we have what’s called Well at Home, so home care patients that meet certain criteria get sent home with a scale, blood pressure, and pulse ox, and that data comes in and alerts the nurse. There are rules associated to it.
It actually also populates the EMR, so when that patient goes in to see their doctor or they need to call their doctor, their doctor can actually see what’s going on with them, which is very cool. And what we hope — and what we’ve been advising with Meditech — is that it will replicate that system where it’s just part of the workflow for the provider when it gets to that side.
Gamble: It’s interesting to see where that can go, because some of the discussion is around not just chronic care, but more of the general population using Fitbits and I think that it seems like there still needs to be quite a bit ironed out before getting to that point?
McColm: Yes. And I think it can be overwhelming for the provider when the patient comes in with all this data — ‘here’s my sleep pattern, here’s how many steps I had, here’s my weight, here’s my blood pressure.’ One thing I hope we can do in utilizing the portal is to normalize all that data so that the provider can actually use it as they’re caring for the patient in an efficient way, and not have five different places they have to go, because it’s already that way with glucometers. All the glucometers will upload, but each brand uploads to its own different little system, and so we have a ton of those around the organization. We need that data to flow in more normalized so that the provider can say, ‘oh, there’s the glucose,’ instead of having five logins.
Gamble: Oh yeah, it actually makes my head spin thinking about it, and I’m not even a provider.
Gamble: So now, in terms of being an independent system, unfortunately that’s becoming more rare, and I wanted to get your thoughts on how the organization is working to remain independent. I’m sure that it helps having that stability in leadership like you talked about, but just some your thoughts around that.
McColm: Well, certainly the stability and leadership are key, and not just at the CEO level, but our boards as well. We have a foundation and hospital organizations and both of those boards have also been very stable over the years. And I think that just staying on that vision has been big. For us, because we expanded out and we’re sort of diversified by having all these lines of service, that served us well over the years. If they cut one area, usually we have some other areas where we can make up for that.
We’ve done some things that don’t even seem to make financial sense, like health transit services, just to help patients stay connected to us. Even if it doesn’t make very much money, we need it for people who can’t get a ride to or from the hospital. I’m shocked how often it’s used just to go from the hospital to one of our own rehab units in our own long-term care facilities; how hard that is for a family to do in a car after a knee surgery.
I think one of the things we’ve done is just the continued growth. We have reached out to some other smaller healthcare systems, so I kind of know what they’re going through. A hospital right up the road from us at Osceola, Missouri closed a couple of years ago. They were a non-critical access hospital and just couldn’t make it. They got some Meaningful Use money, but it wasn’t enough to keep them sustained. They closed down, and we agreed with them to go into their community and provide services. We provide ambulance, rehab, retail pharmacy and a rural health clinic that’s a walk-in clinic for them. And so it’s kind of a sad story for the community to lose that, but we’re trying to kind of fill the void.
Another scenario is, down the right road at Appleton City is a 12-bed critical access hospital, which is a very nice facility, and we are providing the EMR for them. They wanted to be able to meet Meaningful Use and get that reimbursement and also modernize their system, and so we helped them. We host it and now we’ve moved into a management agreement with that hospital and rural health clinic.
We see it happening around us. My guess is the really small facilities will all end up partnering up with a larger hospital system eventually. It’d be tough for them to do something like Meaningful Use on their own. When we first started working with Ellett Memorial Hospital in Appleton City, that same guy that did their IT systems also was security, maintenance and materials management. That’s a lot of hats.
Gamble: Yeah. That type of model is really, really hard to sustain.
Gamble: Now, I wanted to get your thoughts too on innovation — not necessarily talking about new tools and gadgets, but really how your team is able to stretch dollars or stretch resources or just come up with different approaches to a problem, and how you’re approaching that as another way to kind of really stay fit?
McColm: I think it’s sort of a cultural thing. I have been to Kaiser Permanente, it has a beautiful innovation center that cost millions and millions of dollars where they can test out new things. We obviously don’t have those kind of resources. It’s almost the opposite — it’s because we’ve had to stretch our dollars that we’ve been able to innovate and make things work that maybe others wouldn’t think to make work. Even with some functionality of our own EMR system, people will say, ‘wow, you made that work,’ and we’re like, ‘well, yeah, that’s all we had.’
If we wanted to be able to do something like bedside medication verification in our long-term care facilities, it’s very new. Meditech’s functionality was there to do the barcoding, and it’s very important because there are still many meds administered in a long-term care facility; you can imagine with a hundred residents, what they have three times a day. But to be able to hook up to the retail pharmacies that provide us with the medications for those residents with 13 different retail pharmacies that serve our six long-term care facilities, we had to find a way without overburdening those retail pharmacies to hook up with them and help them provide a barcode back to us that we could use to match that medication to that resident. And so with really a few hundred dollars and other than the hardware that we had to have, we were able to set up a system where the prescription goes out via a special smart route that identifies the resident pharmacy, the pharmacy has a little system that we set up for them to put a barcode on the medication, and when it comes back in, then we’re able to match a picture of the resident with their medication before we administer it. There’s no telling how many thousands — maybe more, maybe tens of thousands — of medication errors that’s prevented over the last 10 years. Partly, I think that’s not born out of having a lot to play with to be innovative, but not having a lot to play with and still wanting to do the best we can for our patients and residents.