Q&A with Kate Pierce, Part 1: “Everything’s Not Going to Be Perfect at Go-live.”

“We’re pretty much on an island.”

For rural health organizations, it’s a harsh reality — especially ones like North Country Hospital, a critical access hospital based in Northeast Vermont where “the community is very dependent” on its facilities. In fact, NCH owns nearly every practice in the area, some of which are operating at a loss, just so patients won’t be left out in the cold.

Being a rural health facility means having to do more with fewer resources, getting creative with growing talent, and for leaders, having to wear many hats. To some it may seem daunting, but Vermont native Kate Pierce, who started with the organization 18 years ago as a systems analyst, wouldn’t have it any other way.

Recently, she spoke with healthsystemCIO about the transformation the organization is undergoing to improve workflow, how they’re working with other facilities to better manage costs, and how they’ve been laying the groundwork for the shift toward value-based care.

Chapter 1

• Being a CAH – “The community is very dependent on us.”
• Working with Vermont’s Green Mountain Care Board to control costs
• Migrating to athenahealth’s cloud-based system
• Diverse representation w/ EHR selection & planning committees
• “It wasn’t IT-driven; it was more organizationally-driven.”
• Gaining clinician buy-in
• Go-live expectations – “It’s the baseline.”
• Optimizing documentation

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Bold Statements

At one point, we did an analysis and it turned out we were supporting 173 different applications in over 300 different interfaces. That’s just not a sustainable model.

That has allowed us to become a lot more predictable in our IT costs, because the cost is a percent of your collections. If we do well, they do well. If we don’t do well, they don’t do well.

The leaders of each department were responsible for making sure the software met their needs. Our informatics team would support each one of those directors, but the build decisions weren’t made by informatics or the IT side. They were made by the clinical side.

Every time you have to manually enter information, there’s an opportunity for error. And so it wasn’t hard to get buy-in from providers.

We set the expectation that everything’s not going to be perfect at go-live. Instead, it’s the baseline from where we we’re going to continue to build.

Gamble:  Let’s start with an overview of North Country Hospital — what you have in terms of care offerings, where you’re located, etc.

Pierce:  North Country Hospital is located in northeastern Vermont. We’re a critical access hospital; we have 25 beds. There’s not another hospital for over 40 miles, so we’re pretty much an island, and the community is very dependent on us. We own about 85 percent of the practices in the community.

We have an emergency department and a surgical department, and we offer maternal child health services. We have two large primary care offices and 14 clinics that offer a variety of specialty services for our community. We recently did a community needs assessment to make sure we’re providing all the services that are needed. There may be a few additional offerings that spring up over the next year or two based on that.

 

Gamble:  Right. And you said North Country owns about 85 percent of the practices in the area?

Pierce:  It may be higher than that; I can only think of two practices in the area that are not hospital-owned at this point. One is a pediatrics practice and one is primary care, and they’re both single provider offices. We became owner of all these practices because it’s very hard as an independent physician in a rural community to meet all the challenges. And so the hospital purchased a lot of these practices to ensure that our community still has the services it needs. Many of them we keep open at a loss to the organization as a while, but they’re a necessary service for our community.

 

Gamble:  Does North Country have any affiliations for partnerships at this point?

Pierce:  We have two larger tertiary care centers where we refer patients; both are about an hour and a half to two hours away. One is University of Vermont Medical Center, and the other is Dartmouth-Hitchcock. Generally, we don’t have any stringent affiliations with one or the other, but we have some ties with both depending on the services for which we’re referring.

Usually it’s the patient’s choice. If we need to refer them to a specialist, we’ll ask, ‘would you rather go to UVM or Dartmouth?’ We can transport patients to both facilities via helicopter — Dartmouth-Hitchcock has DHART (Dartmouth-Hitchcock Advanced Response Team), and UVM has a Critical Care Transport team.

 

Gamble:  Being in Vermont, you’re involved with the Green Mountain Care Board. Can you talk about how that works and what it means for the hospitals in the state?

Pierce:  The Green Mountain Care Board is an organization that was put in place years ago. Every hospital in the state — I believe there are 14 — needs to have its budget approved by the Green Mountain Care Board. They have financial oversight, which means that participating organizations have to present a budget to them and explain what you need. They work very hard to help control the cost of healthcare in the state. They’re also the governing body for any projects that exceed $2 million. If a project exceeds that amount, you have to take it to the Green Mountain Care Board and get a Certificate of Need before you can proceed.

 

Gamble:  So the intention is to be helpful, but can the presence of a Board like this pose challenges and slow things down, especially smaller hospitals?

Pierce:  They want to ensure there’s not a lot of duplication of services, and that the services you’re providing are meeting the needs of communities throughout the state. They also want to make sure costs are under control so that as patients, you’re not paying more than you need to for the services you receive. This year, I believe they capped the budget increase at around 3 or 4 percent, so they can control what organizations can charge for services. That’s at a basic level.

 

Gamble:  It’s pretty interesting. Now, what do you have in place as far as the EHR system?

Pierce:  Last year, we actually changed out our entire EHR system. We used to have Allscripts Professional in our clinics, McKesson Paragon in our hospital, and Medhost in our emergency department. That’s just a few. We had a lot of disparate systems that didn’t talk to each other, which is difficult when you think about the amount of work it is to support one of those. For a small organization like ours, having to support those major systems in addition to things like lab and radiology is very challenging.

At one point, we did an analysis and it turned out we were supporting 173 different applications in over 300 different interfaces. That’s just not a sustainable model for a healthcare facility. I met with my COO, and he challenged me to help get us out of the IT business and back into the healthcare business. We’ve developed a plan to strategically move to an integrated system and move a lot of our systems into the cloud; not only would that reduce the cost of IT in the organization, but also complexity. That’s the journey we began last year. We went live in May on a single system that replaced three major systems.

 

Gamble:  Which system did you select?

Pierce:  We selected athenahealth, which is cloud-based. That has allowed us to become a lot more predictable in our IT costs, because the cost is a percent of your collections. If we do well, they do well. If we don’t do well, they don’t do well.

Also, when the regulatory requirements change, instead of having to take three major systems and do an update for each of them, and put all the time and energy and costs to support three different systems — and deal with all the chaos that comes with it — we have one system, and it’s cloud-based.

Now, there’s no downtime for upgrades. Every two weeks they do a little incremental upgrade, and three times a year they do a larger upgrade. But there’s no downtime.

We don’t have to do all the testing and prep work that we did before. We used to do functional testing for weeks, then integrative testing, and then we had planned downtime — all those complicated things you do to upgrade a system that you house in your data center. This is pretty seamless.

 

Gamble:  Let’s talk about the EHR selection process. How was that set up?

Pierce:  We had a selection committee that was made up of our COO, myself, and our lead hospitalist. We have a physician informaticist who works with us, as well as our director of nursing. We had representation from across the organization, including clinical, financial, and other departments.

We had a committee of about seven or eight people that developed a set of criteria for what we wanted in a system. We probably spent about eight months to a year looking at different systems before we chose athenahealth.

Once we started the implementation, it was about a 10-month process. We went live with everything all at once, so it was a big bang. Athenahealth was right there with us; they had about 42 people onsite for the go-live. It was a pretty big deal.

 

Gamble:  What about the EHR planning process? I imagine it was some of the same people involved in those discussions.

Pierce:  It became an organization-wide process. It wasn’t IT driven; it was more organizationally-driven. The leaders of each department were responsible for making sure the software met their needs. Our informatics team would support each one of those directors, but the build decisions — for example, using a template versus a macro — weren’t made by informatics or the IT side. They were made by the clinical side in how we chose to implement them.

We had probably at least 10 to 15 different groups that worked on different aspects, whether it was clinic, rehab, the medical surgical unit, maternal health, or the ED. All the different units had their own groups, and they all had an informatics team member to help support their decisions. There was also someone from athenahealth to explain the software and help them through the decision process. Everyone was involved. Like I said, it wasn’t an IT effort. It was an organizational effort supported by IT.

And that allowed us to get some good buy-in. We went live in May, and by November, we were at 103 percent of collections for the month as projected. We didn’t get that huge lag; sometimes get when you do a go-live; it takes a while for you to transition, especially accounting. So I viewed it as very successful.

That was in May. By the end of March, I had to complete the Most Wired application; we actually were the only hospital in Vermont that was recognized this year as being Most Wired both in ambulatory and acute. So I think it was a good decision for us.

 

Gamble:  I imagine the users understood the need to move to an integrated system, but was it difficult to get people to buy in, particularly since it was a big change?

Pierce:  I don’t think so. I think that they were ready to do something different. They saw all the duplicative efforts. Most patients come in through the emergency department, and so they have to re-enter all their medications and their allergies. You’re looking at two different systems when you try to get their histories, and so you have a duplicated effort in your documentation. And if they decided to admit the patient, you duplicate it again, because now you have to go into a third system to re-enter the medications. Every time you have to manually enter information, there’s an opportunity for error. And so it wasn’t hard to get buy-in from providers. Also, having a physician informaticist helped to drive that with our medical staff.

 

Gamble:  You mentioned that several people from athenahealth were there at the go-live. While I’m sure it was great to have them there, how did you make sure that expertise didn’t leave with them?

Pierce:  We had an informatics person on each one of the committees, so the information that they were teaching us stayed with us. The directors, nurses, and physicians were making the decisions, but we were learning that on the backend. There was a lot of information being passed around.

And after we went live, they didn’t just leave us. We have a client representative who we work with to this day; if we need anything, we talk with this person and she locates a resource that can help us. The go-live is the beginning of your journey; not the end. Everybody works toward that, but we set the expectation that everything’s not going to be perfect at go-live. Instead, it’s the baseline from where we we’re going to continue to build.

And we’re doing that. We’ve done some great optimization work. They have these great tools on the backend that give us monthly reports. For every provider, it shows us how many minutes it takes them to document, how many documents they close same-day, how many are still open, how many keystrokes they have per encounter, and how many macros they use. It’s a complete insight that we’ve never had before into the folks who are struggling with their documentation. It’s a real help for our informatics team to know who’s struggling and where to put resources so we can help them improve. We’re at about 80 percent of same-day chart closure rates, which is much higher than we’ve ever been. All of this helps with billing. Our accounts receivable days are in the mid-30s, which is great.

Chapter 2