When a group of hospitals came together to form North Country Healthcare, it offered several benefits to its member facilities. Not only did it help with recruiting talent and offering more services to patients; it also meant being able to negotiate better contracts.
For Darrell Bodnar, it means no longer having to play “bad cop,” because now NCH had an individual who specializes in contract negotiations and purchasing who can “look at GPO contracts in-depth and push those vendors.” It also means he’s able to focus on maintaining vendor relationships.
Recently, Bodnar spoke with healthsystemCIO about the many ways in which being part of a multi-hospital system – and not a standalone – has changed his team’s approach. He also talked about the journey they’ve been on to move to an integrated EHR platform, how Covid has transformed their virtual care strategy, what he believes is the biggest threat for rural and small organizations, and how brewing beer has become his “therapy.”
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- North Country Healthcare was formed when four hospitals that were “geographically and operationally similar” came together to be better able to recruit physicians and offer services to the community.
- The next stage with NCH’s Meditech journey is optimization, which requires “removing any variances from the process” and enabling providers to “share their services across multiple entities without having to learn new systems, or even learn new templates, workflows, and documentation.”
- After hitting pause on the Meditech rollout for about six weeks, NCH picked it back up because “we didn’t know what Covid was going to bring, but we did know that we could better handle it being on a single system.”
- Like many organizations, NCH is reevaluating its virtual care platform, including what tools are being utilized, and how.
- One of the biggest threats facing rural healthcare organizations are the retail giants and payers who have entered the virtual care and remote patient monitoring games. “It’s going to be a new level of competition that we’ve never dealt with before. And with payers getting into the market, to me that’s a really big risk for rural healthcare.
Q&A with Darrell Bodnar, CIO, North Country Healthcare, Part 1
Bodnar: Every industry needs a catalyst, and ours, unfortunately, was COVID. It put people back on their heels and made them focus on priorities. The healthcare industry is challenged by regulatory requirements and a variety of different things. But, as far as I could tell, they’ve never been as disrupted as they just were — and still are.
It hit right to the core. What was fundamental in terms of our revenue source, no longer is. We were forced to be dynamic, and there were levels of competition coming in from areas we you never expected — mostly due to virtual care delivery, but also from some of the digital giants that are out there. It’s just a very unique time, and I honestly think there are going to be some serious casualties from this as we go forward.
Gamble: I agree. I do want to delve into that, but first let’s get some basic information about North Country Healthcare, which has a pretty unique model. Can you talk about how the organization is structured and how it came together?
Bodnar: I’ll give you the good and the bad. When North Country Healthcare first came together, it was a collection of four critical access hospitals and a home health agency. They came together because we’re geographically and operationally very similar. We’re serving the same patient population, and so competitiveness in terms of recruitment of physicians and offering services was really unsustainable. That’s an industry wide thing.
A lot of organizations have partnered through the more traditional merger and acquisition style to larger affiliate hospitals, and they get swallowed up by the giants. We didn’t want any of that. The CEOs, some of whom were thinking about retirement, came together and said, ‘Let’s try to position ourselves so that we can work collaboratively.’
However, the agreement included an opt-out piece which stated that after three years, organizations could leave if they didn’t feel it was in their best interest. One of the four hospitals, Littleton Regional Hospital, decided to take that opportunity. They departed, and the three remaining hospitals are Weeks Medical Center, Androscoggin Valley Hospital and Upper Connecticut Valley Hospital, along with North Country Home Health and Hospice, decided to stay together. We are bound together.
“Coming to together as a system”
When this happened about 4 to 5 years ago, there were some retirements occurring, and so none of the original leadership is still here. It’s all net new. What made that really nice was that they came in with no historical baggage; of course, they have loyalties to their organizations, but they just didn’t have to commit to some of those historical requirements. They came forward knowing that we were coming together as a system rather than reluctantly being dragged into one. That was a primary focus.
The way it’s structured, we have a CEO that sits over us. We have a president and CEO at each individual affiliate. Those individual affiliates have some autonomy, but we leverage economies of scale and structure to recruit talent, to gain operational efficiencies, and to get financial benefits from contractual negotiations, those types of things, especially now that we’ve solidify onto a single EMR across the systems.
Optimizing to remove variances
Of course, we’re still reeling from the EHR transition. Those are never good, but we’re getting there. As you got to the point where you’re about 7 or 8 months in, which we are, you start to gain some efficiencies. You start to see things. After about a year or two, we’ll start to really start to optimize our systems. The benefit of that is removing any variance from the process and having a single system in which providers can share their services across multiple entities without having to learn new systems, or even learn new templates, workflows, and documentation. That’s why we try to remove as much variance from the processes as we can.
Now, there are certain areas, depending on the service line, where there will be uniqueness to that, but for the most part, we try to avoid it. The idea here is to provide better, additional services that we couldn’t do independently, attract more physicians, and improve the overall outcome of our patients. Because our geography, we’re really intimately involved with our patient population.
Gamble: Can you talk a little more about that involvement? Does that stem from being in a rural area?
Bodnar: It is rural; there’s no doubt about it. And there are challenges that come with it, namely transportation, and in some cases, communication. We’re working with the state and federal government to improve broadband so we can deliver telehealth more effectively. The patient population in Coos County is statistically the poorest in the state of New Hampshire. It’s probably also the unhealthiest in terms of chronic disease.
Caring for these patients isn’t lucrative from a financial perspective, but that’s not our goal. Our goal is to provide sustainable care, and we’re doing that. We’re looking the primary care population that’s being underserved. It’s not a profitability item, but we’re moving forward with it.
We’re also focused on behavioral health and substance abuse, which is a challenge in the area. We’re actually looking at bringing on board impatient behavior health, because the state absolutely needs beds. They don’t have enough beds, and, as is the case in many areas of the country, patients who should be getting care are waiting in EDs and hospital rooms for services that are best offered in mental health facilities.
We’re looking at that. It has never made money for anybody, anywhere, which is why there’s a lack of mental health facilities, but that’s not our goal. The goal is to try to make sure we’re delivering the type of care that needs to be delivered, and doing it in a non-profit world at the sacrifice of profits for other areas. The ones that are profitable help subsidize the others.
It’s just a really interesting time. I myself have never been happier to be in this role. We have wonderful leaders who want to improve care, and we’re starting to look heavily at technology to help deliver that for obvious reasons — not just cost savings, but also effectiveness. So yes, it really is a great time to be doing this. It’s one of the most stressful times you’ll ever go through when you put in an EMR — I’m sure I’m balding and graying because of it, but I absolutely love it.
Gamble: In terms of the EHR, you’re on Meditech Expanse. Are all of the hospitals live at this point?
Bodnar: They are. All three hospitals are on the system, and that covers the acute, ambulatory and ED environments. We went live on Dec. 1, 2020.
Gamble: There are always challenges with an EHR implementation but having to deal with the pandemic as well probably threw quite a wrench into things. How did you navigate that?
Bodnar: It did. We first began the implementation roughly in November of 2019; and started to gear things up with a fairly more robust rollout at the beginning of 2020. Of course, that’s when the pandemic hit, and so we were forced to hit the pause button for about 4 to 6 weeks.
Fortunately, at that time, we didn’t see the impact locally of the widespread outbreak of COVID-19. We had minimal involvement; we didn’t have any inpatients, and so we decided to pick it back up. Originally we were looking to go live at the beginning of our fiscal year, which would have been October 1, and we delayed it until December 1. It was still a rapid implementation under any circumstances. We decided to go forth because of the cost of not doing so, and because we didn’t know what COVID was going to bring. But we did know that we could better handle it being on a single system. As we started to look at the vaccine rollouts earlier this year, it became even clearer that it was the right decision, because we were better able to manage our patient population.
Gamble: Sure. We’ve had a few CIOs tell us that not having a single EHR platform has proven so challenging during COVID. Do you find pretty quickly that it made a difference?
Bodnar: Absolutely. There’s no doubt in my mind that it has had a significant impact. As a whole, care coordination with a single system is much better. The vaccine rollout proved that; it allowed us to move more rapidly to get those vaccines delivered.
Gamble: What have you done in terms of virtual care? Is it prevalent in your area?
Bodnar: It is and it isn’t. Adoption is an interesting thing. What we did see during the immediate ramp up was a lot of Zoom and clinical level software being used. Although it still works well and we still do a fair amount of virtual care, particularly in our behavioral health areas, it has tailed off a little bit as people have come back into the physician offices. I think some of that can be attributed to our geographic location, and some can be attributed to the patient population.
The problem is the reimbursement piece. We don’t encourage it as much because of the rates that are provided. But the reality is that it’s there and it’s still going. Now that we’ve got a single EMR, we’re coming back in and re-evaluating what our virtual care platform will look like. We certainly know a lot more about it now in terms of which areas are more lucrative and acceptable to the service. We’re reevaluating what tools we’re using and how we push those tools out.
Piloting remote monitoring
One area that falls under that umbrella for us is remote patient monitoring, both from a home health perspective and because of some of the chronic disease management we’re dealing with. And that feeds into our EMR directly through our patient portal. We have active pilots going on as we speak to try to provide a more longitudinal look at our patients without having to have them come in for those visits.
Once again, reimbursement is key with some of these. I’m seeing a shift from our payers across the board. Our payers are getting into this virtual care and remote patient monitoring business themselves, which may end up cutting out primary care based on that evolution, which, to me, is one of our biggest threats. As I mentioned earlier, we’ve been protected by the geography of our area. When you look at primary care being offered by some of the larger healthcare providers or some of the digital giants that are out there, it’s going to be a new level of competition that we’ve never dealt with before. And with payers getting into the market, to me that’s a really big risk for rural healthcare.
Gamble: Very interesting. And it’s something I think we’ll start to hear more about going forward.
Bodnar: Even now, Amazon right now is piloting virtual care and mental health services. They have around a million employees; if they can pull this off, like they’ve done with many other ventures, or if Wal-Mart can do it with prescriptions, it wouldn’t take much to cut out primary care. Walgreens is playing into this as well; even Best Buy is dealing in the remote patient monitoring realm because it’s a lucrative opportunity. Unfortunately, what’s the driving referral and revenue process for rural hospitals is primary care and specialty services. To me, that’s a bigger risk. So we’ll see how that pans out. There does seem to be a comfort level across the industry though with virtual care, particularly for our younger generation.
Gamble: Right. Even from a personal standpoint, it’s amazing to see how that has changed in the past year.
Bodnar: It’s convenience and consumer demand, as we’ve seen in every other industry. When the pandemic hit and we couldn’t get 2-day shipping, the country was up in arms. The toilet paper supplies were limited. There’s a level of consumerism that’s already out there. Who goes to a bank these days? Who goes to an insurance company? You don’t do any of those things in person any more. Although healthcare, for the most part, does require certain levels of physical interaction, there’s a big subset of care delivery that doesn’t require that.
A lot of people are looking at that and becoming more comfortable with it. If you do it right, you can deliver 24/7 coverage. When your child has a fever at 2 o’clock in the morning, you don’t have to wait a day or two to see a physician who might not meet your standards. Instead, you can find one online and get that taken care of without even disrupting your life. I think that’s what we’ve all become accustomed to, and healthcare’s prime for it.