John Kenagy, PhD, SVP/CIO & CISO, Legacy Health, Chapter 1

With 20 years under his belt, John Jay Kenagy is no rookie to the CIO position — and yet, he’s continuously learning and evolving. In his current post at Legacy Health, he spends more time than ever before focusing on the best way to bring independent physicians into the fold, working to ease their skepticism while at the same time not “overselling.” In this interview, Kenagy talks about his team’s efforts to facilitate data flow throughout an ever-changing organization, the security “arms race” the entire industry is grappling with, and the “people first” philosophy he’s employing while leading through an acquisition. He also discusses what it has been like to work for four such different organizations, the need for “confident, yet humble” leadership, and what he believes is next for the CIO role.

Chapter 1

• About Legacy Health
• Hosting Epic for community physicians
• Population health: “We’re crossing organizational & legal boundaries.”
• The complex post-implementation world “where we don’t manage all the moving parts.”
• Physician skepticism — “The biggest barrier is switching from a different product.”
• Clinically integrated network “field advisors”

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Bold Statements

We don’t require an exclusivity to join our group or become employed. This is not a subtle way of growing an employed physician base; it really is our mission of being a community hospital system and working with community physicians

I’ve been a CIO at a number of organizations, and I would say that this is the first organization where probably every other day, I’m thinking about how our strategies impact the independent physicians, and how we can exchange data more effectively, and how we can provide them better services.

It’s funny, we literally finished this 20-year pathway in our industry toward system integration and suites of applications, whether that’s provided by Epic or Cerner or Meditech, and now it’s, ‘okay, you’re going to have to work very effectively across this very complex ecosystem where we don’t own or manage or control all the moving parts.’

It’s an interesting message, and you filter it based on your perspective. So if you have less of a trusting relationship or paradigm with the hospital, and the hospital is just trying to take you over or dictate your practice goals, then you’re going to be more skeptical of a program like Epic Connect.

There’s a high penetration of EHR, and switching is a psychological and a technological and an information barrier, but there’s a lot of interest.

Gamble:  Hi John, thank you so much for taking some time to speak with us today.

Kenagy:  Sure.

Gamble:  To give our listeners and readers a little bit of background, can you talk a bit about Legacy Health?

Kenagy:  I’m happy to. Legacy Health is headquartered in Portland, Oregon. It is the only locally controlled managed health system in Portland. As of June 1st, we now have seven hospitals, with Silverton, Oregon, about an hour and a half south of Portland, joining our system. We have two anchor urban hospitals, Emanuel and Good Samaritan, three suburban hospitals, one rural hospital and a children’s hospital. We were founded in 1875 with the Episcopalian community wanting a health system to serve them, and about 25 years later the Lutheran community had the same goal, on the east side of the main river that runs through Portland, Willamette, and we have been going strong since then. It’s a great organization local here to Portland and Southwest Washington.

Gamble:  Looking at the clinical application environment, you have Epic in the hospitals?

Kenagy:  We do, at all of our hospitals. At Silverton, which just became a part of us, we will be replacing five actual local EMRs with our enterprise Epic solution. So yes, we have Epic. We first went live in 2010 and have it across all of our clinics and all of our hospitals, and we host it for local physicians.

Gamble:  And as far as the physicians, what is the mix there as far as owned or affiliated?

Kenagy:  Great question. We are very much a community medical center. So unlike an academic or Kaiser, which has more of a group practice model, we have about 2,000 physicians on our medical staff, and about 500 of those are employed. More recently, we have formed a clinically integrated network, like many health systems. It’s one of our priorities I’m working on right now, and that is made up of about 2,000 members. Our medical group forms one of the four pillars of that clinically integrated network, with the others being adult specialty, adult primary care, and pediatrics.

Gamble:  That’s definitely something that’s starting to pop up more. What stage are you at this point with the clinically integrated network?

Kenagy:  We’re in our second year. We formed it in calendar year of 2014 — that was sort of the strategy setting, 2015 was the first year, including having the formation year, and this year, 2016, is the second full year in operation.

Gamble:  What are kind of the immediate priorities with that?

Kenagy:  That’s a great question. Information is a big one. I’m hesitating because I don’t want to sound so self-serving, but if you think of clinical integration, that really is going to be the free flow of information. It’s going to be things like a common set of quality measures and goals and objectives. The clinic integrated network will also be on the health market as a practice, as a group for insurance or direct-to-employer contracting, so there’s a number of formational issues. Some of its key goals are what they call under the rubric of citizenship goals — being trained, going to orientation meetings, and participating in governance function, and so there are a lot of formational goals for that. But a huge opportunity there is the clinical data integration from multiple disparate EMRs to work together for the betterment of patient care of the community.

Gamble:  Who are the other organizations that are involved, other hospitals or practices in the area?

Kenagy:  It’s all practices. Legacy is the anchor health system. We call it Legacy Health Partners, so it is our hospitals and our medical group, but as I said, the other four pillars are community physicians who are not employed by Legacy. They may be part of other clinically integrated networks — we don’t require exclusivity. Portland’s a highly competitive healthcare marketplace with four dominant players and a number of medium-sized insurance companies. We don’t have any for-profit hospitals in the area or the really large national insurers, but we have a lot of local insurance, and a large presence of Kaiser Permanente, and so physicians really have a lot of choice in where they go, but also many of them are all-comers when it comes to insurance, and so we don’t require an exclusivity to join our group or become employed. This is not a subtle way of growing an employed physician base; it really is our mission of being a community hospital system and working with community physicians who, as long as they desire to be independent, that’s great, and this is just a different way in which we can participate.

It’s interesting; I’ve been a CIO at a number of organizations, and I would say that this is the first organization where probably every other day, I’m thinking about how our strategies impact the independent physicians, and how we can exchange data more effectively, and how we can provide them better services. We have a very strong outreach program. Under IS governance, one of our subcommittees that works under IS governance is our community systems governance. It’s all about attempting to provide the best care and a strong level of support for our affiliated physicians.

Gamble:  Right, it’s becoming a bigger part of the picture as organizations focus more on population health and bringing that into the fold. 

Kenagy:  Exactly, and what’s more complicated about that is obviously we’re crossing organizational boundaries, legal boundaries. Doctors’ offices are generally for-profit, small enterprises. We are clearly crossing technical boundaries with multiple EMRs. What’s interesting is, we at Legacy Health, along with every other health system, certainly after the HITECH Act was passed and the incentive program for meaningfully using a certified EHR — we actually started our journey before that, and have been advanced in the use of healthcare information technology. But we had this goal as an organization to put all of our systems into an integrated Epic platform, basically an integrated system with the patient at the center, and spent $100 million and about two and a half years in designing, building, testing, training, configuring and then launching the system, which itself, replaced two major electronic health records, as well as multiple different subsystems. We had this journey to really bring it all together. And when you finish the implementation, really that’s the start of this wild ride. But you begin with optimization and all that, and a knock comes on the door saying, ‘that was great, thanks for doing it,’ or maybe not even a thank you, just, ‘okay, here’s what’s next. We need you to integrate that data across NextGen, Centricity, ClinicalWorks, Sage, Intergy.’ It’s like, ‘all right, you’re welcome for getting HIMSS stage 7 across all of our clinics and hospitals, now what’s next?’

The whole drive in the population health and basically working within a very complex healthcare ecosystem — all of that requires a high level of EHR adoption and use. It’s funny, we literally finished this 20-year pathway in our industry toward system integration and suites of applications, whether that’s provided by Epic or Cerner or Meditech, and now it’s, ‘okay, you’re going to have to work very effectively across this very complex ecosystem where we don’t own or manage or control all the moving parts.’

Gamble:  And when you talk about that, I’m sure that’s where things like the clinically integrated network come into play, but really being able to engage with those physicians and to take the approaches that are needed to be able to integrate the information without trying to force the hand too much. I can imagine that’s something that gets a little tricky.

Kenagy:  Yes. Yes, and there’s the tricky technologically, but there’s also the tricky politically. I think it’s overly stated how physicians at times don’t trust the hospital system that they are part of, and we go to great lengths to really make this the physician’s choice. We at Legacy have a couple stories to tell, because we’re also hosting for the physician community if they want to be part of Epic. We don’t make a profit on that. It’s an interesting message, and you filter it based on your perspective. So if you have less of a trusting relationship or paradigm with the hospital, and the hospital is just trying to take you over or dictate your practice goals, then you’re going to be more skeptical of a program like Epic Connect, which we call Legacy Epic for Affiliated Providers, and be more resistant to that. Or here we want to connect with you if you’re on NextGen or eClinicalWorks, we want to integrate using HITECH Act standards or certainly the HIE standards that continue to grow under the federal certification of EMRs, or you can join part of our Epic, and that, at times, is seen skeptically.

We’re very excited about Epic. It has made a big difference at our organization, but you’re selling it, and so is there a conflict of interest in working with us as an independent physician with our own EMR when you’re also a competitor. You’re a provider of collaborative services, but you’re also a competitor to my EMR. We really aren’t, of course, because we’re not a for-profit organization, and we really go to great length to explain we’re with you, however you want to be.

Now of course if you’re not on an integrated platform, that’s not going to be as seamless for the exchange of patient information as it is if you share one patient record. So there’s a little bit of education in terms of what’s possible through integration. Frankly, if you’re on one Epic to another Epic, it’s not the same as being on a completely shared platform. There’s still a lot of exchange between our Epic and other Epics and other EMRs, but that’s the nature of where we are as an industry right now.

Gamble:  Yeah, and you’ve had a fair amount of interest in the hosting program?

Kenagy:  We have. I think the biggest barrier is switching from a different product. I would say proudly that in Oregon as a state, or certainly the Oregon region, the physicians in this area have been fairly early adopters of electronic heath records. Of course that makes some sense because Centricity, which was MedicaLogic, was founded in Portland, and a number of physicians adopted it early on. It was really a significant KLAS winner for small size practices a decade ago, and there was a lot of adoption of EMRs, and then of course HITECH Act encouraged more physician offices to do that. We have some IPAs that host EHRs for physicians who want to become members. So there’s a high penetration of EHR, and switching is a psychological and a technological and an information barrier, but there’s a lot of interest. We have an ultimate goal of trying to get 500 community physicians on our electronic health record. I think we’re at more than 200, and we have some really unique offerings too, we can touch on in a minute.

Gamble:  Who’s having those conversations as far as with those clinicians? What type of set up do you have as far as doing that outreach?

Kenagy:  That’s a great question and it continues to evolve. Right now — and I actually think it’s a really smart division of labor — the clinically integrated network, which we call Legacy Health Partners, has field advisors who are interacting with our physician members of the clinically integrated network. A couple of those field advisors have become specialists in talking about our program and working with the practice to see is this right for you, what does it mean, what are the costs, what do you have to have, how would we do it. But all of the field operations advisors are well trained in our program, and they’re the in-the-office marketing arm, sales and marketing.

And then we have a separate department within our IS division that provides all the customer service — the build, the support, the cutover and implementation training, and ongoing optimization. We have a fairly large 25-person department that supports our physicians. The overall program for Legacy is jointly managed by our chief medical officer who has the strategic accountability for our physician engagement strategies, and then the SCIO, who have responsibility for the technology and system integration and all that.

Chapter 2