If you think your organization has a hard time gaining access to data, trying working with the military. For organizations like Fort Drum, it has long been a struggle to provide clinicians with updated health records of military members because of the firewalls that exist. But finally, there’s a light at the end of the tunnel, says Corey Zeigler, whose organization is participating in a pilot that could finally break down those walls. In this interview, he discusses the unique operating model that he believes will position Fort Drum well for the future; the governance challenges that come when hospitals aren’t owned; and how his team is leveraging an HIE to pull together data from multiple EHRs. Zeigler also talks about the organization’s population health journey, his military background, and what it’s like to get outside the four walls of the hospital.
- DoD HIE pilot — “It strengthens our integration with the military.”
- Military firewalls — “They’re shy about directly connecting with anyone.”
- A blueprint for integrated care
- Eyeing population health
- Data access hurdles — “It’s going to be a key driver as we go forward.”
- Leveraging EHR-generated reports to present “a complete picture”
- Focus on “where we can provide the biggest impact.”
LISTEN NOW USING THE PLAYER BELOW OR CLICK HERE TO SUBSCRIBE TO OUR iTUNES PODCAST FEED
We’re committed to supporting them in that we’re trying to avoid duplicative work of building private HIEs or trying to circumvent the RHIO. If it’s in their business model to provide the services, they’re always our first go-to.
The military is fairly shy about directly connecting to anyone, and so being able to securely and reliably exchange information with the military to pull them into our healthcare system, or us into theirs, is fantastic, and it really strengthens our integration with the military in the community.
Now many of the other installations that have healthcare facilities are looking at this model because we’re able to provide very high quality care for the soldiers and their families at a fraction of the cost of maintaining their own infrastructure and facilities on post.
We have to be able to show them and let them use that data, but not the data that they’re not authorized to see. I think that’s going to be a key driver as we go forward in communities like ours that aren’t on one system or in a fully integrated network. When you end up with all of these separately owned and operated facilities with separate payers, it forces you into this model.
We’re gathering flat file extracts from each of the ambulatory EHRs — we’d like to use the standard base exchange or the CCDs, but what we have found is that all the data that is needed to run these measures, the specific data elements, many times they’re not in the CCDs, so we wouldn’t be able to report on those if we didn’t go back and do manual extracts.
Gamble: Obviously a lot of HIEs have had issues with sustainability but in your case this is one where you really need it for getting all this data together. Is it the funding model that’s helped it to sustain over the years?
Zeigler: They’ve tried a couple different models. For a while they were receiving funding from the payers on a per inpatient admission standpoint to augment their funding. When that ceased, New York State picked up a lot of their operational cost. It is a tough model from a sustainability standpoint, but I think we’re committed to supporting them in that we’re trying to avoid duplicative work of building private HIEs or trying to circumvent the RHIO. If it’s in their business model to provide the services, they’re always our first go-to for those services. It’s only if they absolutely cannot support those services or something they do that we go to try and build something ourselves.
Gamble: Right. And the Department of Defense is involved, or at least that information is going back and forth?
Zeigler: Yes, we’re one of the early pilots for this full integration. We are in the midst of our operational test right now across the Department of Defense. They’re headquartered out of Colorado Springs. They first got the VA live with the HIE in 2014, and then this past fall we started and we pulled in the army and the active duty folks in the DoD. Now, we’re doing a full operational test here, and it’s going very well. So our providers in the community and our hospitals in the community can go on the HIE portal, and when they look up a soldier or family member — with consent — they can pull up not only the care that they received in the community, but also the other military records. And then vice versa on Fort Drum — through the VLER (Virtual Lifetime Electronic Record) and the JLV (Joint Legacy Viewer), their providers can immediately see any cares that they’ve received in the community here. So it really puts everybody on the same page, which was kind of a career high for me because I’ve been trying to get this in place since 2006.
We put in a fiber network all over New York, from Albany all the way up North near to Canada and to the West, right over here to Lake Ontario then back down to Syracuse. With all this fiber in, we went to Fort Drum with a wire in our hand and said, ‘we really want to connect you to our network.’ The military is fairly shy about directly connecting to anyone, and so being able to securely and reliably exchange information with the military to pull them into our healthcare system, or us into theirs, is fantastic, and it really strengthens our integration with the military here in the community. Because there’s nothing more personal than healthcare, and if we do a good job at taking care of the soldiers and their families, it’s one of the best things we can possibly do for.
Gamble: Sure. And is this just something where there was a lot of red tape and you just kept running into one issue or another?
Zeigler: Yes. As you can imagine, I mean with all the security issues, that’s all we hear about. I’m on a planning committee for the CHIME Fall Forum, and security is such a hot topic. We’ve seen hospitals get hit with the ransomware or been hacked. We have foreign nationals and other governments trying to do bad things. The military is very sensitive about that. They have accredited systems. Even if you’re on Fort Drum and you’re, let’s say, a contractor or something like that and you have a computer system, if you’re going to even turn that thing on, you have to go through an accreditation process. What they’ve done is they’ve created these intermediary accredited systems, and so the information comes from the military and it’s checked and made sure that there’s no classified information in that data, and then it’s released out to the civilian world, and vice versa. When it comes in from the civilian world, it’s checked and made sure that there’s no malicious information in there before it is then transferred over to the military side. So there’s kind of a DMZ or a firewall there between the two systems that’s accredited and controlled by the military. And that makes them comfortable and obviously, if they’re comfortable, we’re comfortable.
Zeigler: Probably a lot of detail there.
Gamble: No, that’s alright. I can just imagine that challenge that it’s been just trying to get these records from this huge portion of the patient population.
Zeigler: It has, and it’s incredibly inefficient if you think about all the phone calls and all the faxing and all the hand-carry documents that are used. They used to call it sneakernet when you hand-carry stuff places to the care for folks, and invariably they’d show up for surgery or something like that and they wouldn’t have the labs, and so they’d either have to do them over or they’d have to go find them. We’re already seen huge improvements in that.
Gamble: Yeah, that is huge. Now, you said this is a pilot, so they’re going to keep monitoring the progress and then go forward from there?
Zeigler: Exactly. The whole model that we have here — and I don’t know if I mentioned this in the beginning — is that it was a pilot of this integrated care system, and we were taken off pilot status in 2011. And now many of the other installations that have healthcare facilities are looking at this model because we’re able to provide very high quality care for the soldiers and their families at a fraction of the cost of maintaining their own infrastructure and facilities on post.
Gamble: When you talked about it in the beginning, I was thinking it sounds like a forward-thinking idea — rather than taking all the resources that are needed to build this hospital, you’re utilizing the hospitals and physician practices that exist and connect them. That’s a strategy that looks down the road, it seems like.
Zeigler: Absolutely. And it doesn’t just benefit the military, it benefits the community here, because we’ve threw in 40,000 covered lives that we’re able to support and we have access to specialty care that we wouldn’t otherwise have if we weren’t a larger system; and they do the same thing with the school system too. Fort Drum’s children attend the community schools and that provides federal funding to the schools. So we’ve really have this partnership on all these human services areas that have been just fantastic for folks.
Gamble: You mentioned the Population Health Management and can you talk a little bit about what you’re doing there?
Zeigler: We’re in the last stages of contract negotiations right now with a new vendor. So the jury’s still out on that, but we’re very confident that that’s going to be a key solution for what we’re trying to do. One of the main components that we needed, which I’ll bring up because I think it’s going to be critical for any area that’s going to get into this type of arrangements with payers, is the ability to track and tag data from its source. It’s something our previous vendor couldn’t do. Basically, if you had access to a particular patient’s information, it was either all or nothing. You either saw their chart from a patient’s perspective because you had authorization or consent, or you did not. What we really need is if you have access to all the data or just some of the data. SO if you’re not participating in a particular payer program, that payer does not want you to see their data. There’s pricing confidential information in there for New York Medicaid data — we absolutely have to control that one. They give us the data that only those that are authorized can see that Medicaid data. But yet we’re receiving all these clinical feeds, and folks want to be able to see and run reports and do risk modeling and whatnot with their own data. So we have to be able to show them and let them use that data, but not the data that they’re not authorized to see. I think that’s going to be a key driver as we go forward in communities like ours that aren’t on one system or in a fully integrated network like Kaiser or Geisinger or some of the other larger systems. When you end up with all of these separately owned and operated facilities with separate payers, it forces you into this model. And I think that you don’t want to let that slip by you and have it not be a capability of your PHM, because otherwise they just don’t see how it would work.
Gamble: Right. That really sounds like a lot to keep track of, and there’s really room for error when you’re dealing with all of that.
Zeigler: Yes, but we’re really looking forward to the information that we’re bringing in there. We’re actually gathering flat file extracts from each of the ambulatory EHRs — we’d like to use the standard base exchange or the CCDs, but what we have found is that all the data that is needed to run these measures, the specific data elements, many times they’re not in the CCDs, so we wouldn’t be able to report on those if we didn’t go back and do manual extracts.
So we’re automating that, but generally speaking, it’s a report that comes out of these EHRs that helps us in the couple ways. One, the EHR vendors are not very flexible when it comes to changing their interfacing. They’ve got it set up to meet Meaningful Use requirements, and if it’s not a Meaningful Use requirement then they just don’t have the bandwidth to do a bunch of changes. But this allows us to control that from an extract. And then of course, any changes that we need, we can say, okay now we need this piece of data, we could go back and add that to the extract and be able to collect that data. Then once we get it in the system, we’re really using that to drive three major areas. One is to risk-stratify the patients and focus our scarce resources on where we can provide the biggest impact, primarily with care management. So we’ll create a panel for the care managers and help them manage those. We’re also using remote monitoring in the home via telemedicine.
And then also to look at cost and utilization with the claims data and merge that claims data with the clinical data, which goes back to that point before that you have to be able to control that. By bringing both the claims data and the clinical data together, you really get the best picture or the most complete picture. There’s a lot of information in those claims files that is key to fill in the gaps on whether or not the patient received the particular care or screening, and sometimes that the only place you can get it is from that claims file. And then of course, presenting some decision support at all levels, from the provider that day with that patient or at their morning huddle, or with our patient-centered medical homes, all the way up is what we’re focused on to make the biggest impact on the population we’re supporting.