For this annual year-end feature, Health Data Management posed a simple question to CIOs and other executives facing payment reform, dwindling reimbursements and pressure from patients, payers and employers for increased transparency around quality and cost: What I.T. do you need most in the year ahead, and beyond?
To a person, these executives described the current health care environment as one of unprecedented change. Their answers offer insights into just how turbulent the industry has become—and why I.T. is at the center of what they view as necessary safe harbors.
Looking for Analytics
Name: Praveen Chopra
Title: Chief Information and Supply Chain Officer
Organization: Children’s Healthcare of Atlanta
Description: 500-plus bed, three-hospital delivery system
Praveen Chopra wears two hats for Children’s, which staffs 500-plus beds across three hospitals. In his CIO role, he oversees clinical I.T.—whose core is an integrated clinical and financial system from Epic. In his supply chain oversight role, he oversees strategic sourcing of supply purchasing, purchase order management and inventory control, activities largely supported by a Lawson system.
Chopra estimates he spends 80 percent of his time on the clinical side of operations—the area where most of his I.T. “wishes” reside. Chopra’s foremost wish is for improved data analytics, a system to work in conjunction with his EHR and other clinical and financial systems. He describes the pediatric health system as “data rich and information rich, but not rich in insights.”
The analytics market, Chopra says, is crowded—unlike the EHR market, where a handful of players dominate the inpatient side. “Analytics is maturing at such a fast pace,” he says. “So we need to figure out what we need and match that with what is available. No one vendor has a comprehensive suite.”
Children’s Healthcare needs to build analytics capacity to measure quality outcomes, financial performance and overall population health. He’s eying predictive analytics, a way to forecast, for example, which patients might be most at risk for readmission. A second, related wish is for improved patient registries with analytics underpinnings.
“We need a real-time tool,” Chopra says, describing his ideal set-up as one in which patient registries would be linked back to the Epic system to alert caregivers about missing tests or other evidence-based activities and then lead them to the appropriate order set within the EHR during the visit. Epic currently includes some registries and Chopra is looking to forthcoming upgrades with more functionality. The patient registry, he says, will help uphold future accountable care contracts, in which the health system will be paid based on outcomes more than volume of services rendered.
“If a patient has an asthma attack and goes to the ED, we take care of them and send them home,” he says. “We want to avoid the patient showing up in the first place.” Chopra’s third wish is that Children’s can begin to embrace existing mobile technology to help reach patients at home.
“Traditionally, with telemedicine, we think you have to buy custom equipment,” he says. “But people have iPads and we need to ask how we can innovate our care through that existing technology. A person could take a picture of their sore throat and upload it to their physician.”
In essence, he wants to extend the BYOD idea to patients. But first, Chopra needs to engage physicians in the idea. “We are just starting BYOD with physicians now,” he says, pointing out that clinicians can use their own devices to access their e-mails and contact lists. A pilot is under way now in which physicians will access Epic on either their own tablet or smart phone. “We are clear about what needs to be done,” Chopra says. “The only question is how quickly we can synthesize the tools available to meet our needs.”
Wanted: Substance Before Style
Name: Rasu Shrestha, M.D.
Title: Vice President, Medical Information Technology
Organization: University of Pittsburgh Medical Center
Description: 20-hospital integrated delivery system
When it comes to I.T., UPMC has spent big—more than $1 billion in clinical and financial information systems over the past six years, according to published reports. The health system—which also runs a 1.3 million member health plan—has used a best-of-breed approach as it automates operations.
It falls on Rasu Shrestha to evaluate new and emerging technology to add to the mix or replace outdated applications. That may explain why his biggest wish is not for a particular technology, but rather a culture change among the vendors he considers. “We need better alignment among vendors,” he begins. “Their motivators and drivers are quite different than those of hospitals and physician groups. That is extremely worrying.”
I.T. vendors overall tend to focus on their own product and market position, rather than how their software will fit in with customer operations, he contends. “Vendors are incentivized to sell more systems and have market domination. But the notion of interoperability and working more harmoniously across multiple other vendors’ apps is not in alignment with that. We want our system to work together, to enable better care coordination and improved population health. It is a big struggle for us. Our workspace is a composite of siloed information systems that we use together.”
Through its own interoperability efforts, UPMC has been able to create a longitudinal patient record, Shrestha says. And he praises the meaningful use program with pushing vendors to adhere to more data standards.Nonetheless, he says “a lot of vendors do just the bare minimum” in working with other applications.
Shrestha says that health I.T. vendors lean too much on hype, a hurdle he must clear before he can analyze any given system. “I need more substance and fewer buzz words,” he says with a sigh. “Vendors tend to throw out terms like ‘mobility’ and ‘cloud-enabled’ but they don’t give you much insight into what they are really about.”
His least favorite buzz word? “Big data,” answers Shrestha without a pause. “Big data deals with genomic sequencing and dealing with millions of data feeds. You hear vendors talk about ‘big data’ but it’s really medium-sized.”
UPMC itself is rapidly becoming a big data showcase. The delivery system houses five petabytes of data across all systems, an amount that doubles every 18 months, Shrestha says. The vice president does have one app-specific wish: He hopes the industry can develop an “untethered personal health record,” to which patients can download information from their providers and port wherever they need.
Currently, UPMC has three PHRs of its own in place—originating with its inpatient, ambulatory and health plan benefits administration system. This year UPMC launched a project that would link together those three systems, Shrestha says.
But he envisions a day when patients can maintain their own PHR, one not extracting data solely from any given EHR. The technology, he says, “would help keep patients engaged in their own health. We need much better coordination across multiple clinical scenarios. There’s a chance for better coordination across a larger span of geography and it comes back to the patient.”
Primary Care Focus
Name: Bruce Bagley, M.D.
Title: Chief Executive Officer
Description: American Academy of Family Physicians subsidiary
Launched in 2008 by the American Academy of Family Physicians, TransforMED has a straightforward mission, says CEO Bruce Bagley. “We want to fortify primary care and promote the patient-centered medical home model,” he says.
The organization has grown to more than 50 employees and sports a $10 million yearly budget to support its work with health systems and health plans. Its customers go beyond family physicians, however. “Primary care includes internal medicine, pediatrics and nurse practitioners,” Bagley says. “They all need to remain laser-focused on the ‘triple aim’ of better individual care, improved population health and improved per-capita cost of care. We need information systems to help with all three. You cannot choose two. If we lose sight of that, we will be off the mark.”
Bagley says one key piece of technology is needed to support that goal. “The most important tool for primary care—one that has been slow to integrate into the EHR—is a disease registry at the point of care,” he says.
Bagley says the ideal disease registry supports five functions. First, it must be able to present all patients under a given diagnosis, such as diabetes. Second, it must provide a snapshot of each of those patients so that, during encounters, providers can easily see care gaps, such as missing tests. Third, the registry must aggregate all the patients in the practice and reveal basic analytics about the group, such as what proportion of diabetics have their blood pressure under control. Fourth, the registry should support outreach efforts by administrative staff, who can contact patients as needed and encourage them to come in for visits. Finally, the system needs to enable the type of quality reporting increasingly being demanded by payers.
According to Bagley, EHR vendors have been slow to include registry functions in their core systems primarily because physicians have not asked for them. “There are some good stand-alone registries, but they are not integrated into workflows,” he says. “A good registry could help providers risk-stratify their care management.”
Sparked by a $20 million innovation grant from CMS, TransforMED is working with two vendors—analytics vendors Phytel and Cobalt Talon—to help build what Bagley calls “the medical neighborhood,” or the ability of local practices to easily coordinate care. Bagley’s vision is that the project will result in the type of registry functions practices need to uphold the triple aim. Phytel’s registry function—which works in conjunction with various EHRs—will supplement Cobalt Talon’s financial analytics capability and give feedback on the cost of care. “Being able to juxtapose the two helps,” Bagley says.
“If we are expected to have influence on cost and quality, we need the data to do it.” Bagley concedes however that IT alone is not enough. That’s why another of his wish list items revolves more around culture than computer science. He recalls speaking before a group of 350 business leaders and posed the question: How many of you e-mail your doctor? “Only one hand went up, and he was the CEO of a health system and he probably knew the physician personally,” Bagley says. “That’s where the problem is. People are not using the technology we have. Why aren’t we using e-mail and Skype? When we talk about telemedicine, we talk about expensive gadgets, not the stuff that is out there. We should use the technology that is available.”
Bomb-proof Back-up system
Name: John Vaughan, M.D.
Title: Director, Medical Informatics
Organization: Sharp Health System
Description: Seven-hospital delivery system
John Vaughan acknowledges that his I.T. wishes reflect more a desire for incremental improvement than the gaps he sees in Sharp’s portfolio.
The highly automated Sharp runs a number of systems including Cerner on the inpatient side, Allscripts on the ambulatory side, GE for billing, Fuji for imaging and Hyland for document management. It’s a complex array with multiple interfaces—and occasionally the system goes down when a component piece doesn’t operate properly.
Thus Vaughan’s first wish is for “a bombproof back-up system with instant fail-over with 100 percent data reliability.” San Diego-based Sharp is getting better at minimizing downtime, he says, but it is still a critical need. “The EHR is in all of our hospitals and the physicians are more dependent on it and expect high reliability.” Vaughan estimates that Sharp’s uptime is in the 98 percent to 99 percent area, but “needs to be 99.6 percent or higher.” There are many possible areas that can cause the overall system to crash, he says, citing multiple pieces of equipment, switches and servers in play.
He praises both Cerner and GE for providing a “huge amount of vendor support” when problems arise—as those two systems interface with many others, such as medical devices. Sharp is beginning to migrate more medical devices—such as fetal monitoring equipment—to indigenous Cerner software, a step that should minimize downtime even further, Vaughan says.
Vaughan has one long-term wish: the ability to accept and analyze genomic data. “This is many iterations down the road,” he concedes. “San Diego has a huge bio-tech industry and we are starting to see some demand from patients for genomic data,” he says. Cerner has a project under way now that would enable its EHR to accept some genomic data, Vaughan adds. Those kinds of efforts will “fortify what we are already doing.”
A Long Laundry List
Name: David Taylor
Title: Vice President, Regional Services
Description: Five-hospital integrated delivery system
David Taylor is a practice management executive at CoxHealth, a $1.2 billion system that includes two medical groups spanning 225 physicians and another 80 mid-level providers. Cox began using EHR technology nearly 15 years ago, Taylor says, and has brought in multiple systems as needed. “We are moving from best of breed to an integrated approach,” he says. “We need to have our systems aligned just like we have our physicians aligned.”
Taylor’s I.T. wish list is long and varied—and he attaches no particular priority to any one item. But at the core of his list is one underlying theme: the need for more data integration among systems and an improved user experience. Taylor says Springfield, Mo.-based Cox is gravitating to an integrated system on the Cerner platform—a move that, if all goes as planned, will address his wishes for such things as integrated functionality, shorter implementation cycles and improved device interoperability.
The first step toward the integrated portfolio of Taylor’s dreams was outsourcing the organization’s entire IT operation to Cerner, a move that happened late in 2012. Now some 120 I.T. staff are Cerner employees, helping to staff the data center at the EHR’s Kansas City headquarters, oversee implementations and create new interfaces. Cerner’s ambulatory module will supplant Cox’s current system, from GE, which also provides billing software for most of Cox’s 75 physician clinics (a handful run on yet another platform).
Taylor says Cox may maintain the GE billing system, but has not yet decided on using Cerner for that. Taylor points to medical device interoperability as a big need moving forward. Like most health systems, Cox sports an array of ultrasound equipment, EKG machines and IV pumps, “all with different languages and operating systems,” Taylor says.
In many cases, the readings from those devices must be manually transferred to the EHR, a source of potential errors. Cox has some ultrasound units feeding data directly into Cerner, as does its lab equipment. Next up on the agenda is mammogram readings. The best-of-breed approach has revealed the source of another of Taylor’s frustrations: overly long design cycles and upgrade releases from software vendors. “Version upgrades can take a long time and it seems like it takes forever to get to the promises made,” he says. “We are a health care provider, not an I.T. solutions company.”
That dependency on third-party software creates anxiety among system users expecting new upgrades or capacities, he says. By outsourcing the I.T. operation to Cerner, Taylor is optimistic that more resources will be available to Cox and will help it manage upgrades more efficiently.
Some of his needs relate more to physician practice habits than the underlying software. One of Taylor’s wishes, for example, is for more discrete data capture. He’d like a way to extract data from dictated physician reports, which form the cornerstone of much of the health system’s documentation. Cox has made headway in capturing physician documentation via speech recognition and, right now, physicians dictate directly into Cerner. That has helped Cox winnow its annual transcription tab, which once stood at one-half million dollars, to around $25,000.
The only issue is that the narratives are difficult to mine. Cerner enables point and click documentation via pull-down menus, but many physicians prefer dictation. Taylor is hoping that natural language processing software will mature to the point where that narrative text will be minable. And he sees less resistance to template-driven, pull-down documentation from physicians emerging from residency programs—a group that has grown up with I.T. The final I.T.-related wish Taylor expresses is for regulatory relief. “Regulations are squeezing health care and the environment is so complicated now,” he says.
Cox is attempting to uphold meaningful use for its providers, and tracking that for such a large medical group is labor-intensive. The health system is facing Medicare penalties as well if it doesn’t meet the requirements of the federal Physician Quality Reporting System program. The PQRS effort includes multiple—and specialty-specific—reporting on the part of physicians, who otherwise face a 1.5 percent reduction in Medicare payments for non-compliance (the American Medical Association and other groups are pressing for relaxation of certain rules).
Taylor says that the data needed to uphold the two programs resides in its current I.T. set-up, but that creating the reports “is a very manual process.” Taylor’s especially skeptical around the value of ICD-10, the forthcoming coding and classification system mandated by CMS to launch October 2014. The specificity required by ICD-10, particularly in such areas as external cause of injury location codes, provides little value to physicians, he contends. “The ER doc doesn’t care if an injury occurred in a house, factory or parking lot,” he says. “They just don’t get that.”
Name: Gina Genenbacher
Organization: Blessing Physician Services
Description: 50-physician multi-specialty group
Blessing is an employed physician group, owned by its namesake hospital in Quincy, Ill. The practice runs on an ambulatory EHR, from Allscripts, which also provides the hospital’s inpatient system (from Eclipsys, which merged with Allscripts).
The two systems interface, and for individual patient encounters, work quite well, says Gina Genenbacher, director. But she’s looking beyond the individual encounter to the future—one in which the group will be paid on how well it takes care of populations of patients and upholds quality metrics. To that end, Genenbacher would like an analytics tool that overlays the disparate care settings. Right now, Blessing’s patients get many of their imaging tests done at the hospital. And those results flow back to the group practice in PDF files that are scanned and then appended to the patient chart.
The hospital has a variety of other systems in play too—lab and PT, for example—from which Genenbacher would like to capture discrete data. Or, if that is impractical, she’d like to be able to parse the data and analyze it to help manage groups of patients more efficiently. Blessing Hospital is forming a team now to analyze its options, she says. Her other wish is for improved data sharing among group practices and even other hospitals in the region. “We’re not unique,” she says. “The entire industry needs health information exchange.”
Under way now is a project—called the LincolnLand HIE—that ostensibly could meet that wish.
Tackling Industry Deficit Disorder
Name: David Muntz
Title: Chief Information Officer
Description: Interactive patient information software vendor
Before he joined GetWellNetwork two months ago, David Muntz logged two years as principal deputy national coordinator and chief of staff at ONC, the federal department charged with running the meaningful use program. Muntz says a top priority for the industry is “the ability to focus.” He describes the current environment as representing “the most radical changes in health care and IT that we’ve ever seen.”
By that, Muntz is referencing to the spate of federal initiatives, including not only meaningful use but also health reform and ICD-10. Muntz describes his underlying industry wish as “true interoperability—not just the ability to exchange data among systems, but to use data in a meaningful way. It requires an awful lot of pieces in the mosaic. When complete, you get a good picture of the patient.” That’s the reason he gave for leaving ONC (at the same time as did his boss, Farzad Mostashari) for GetWellNetwork, which supplies interactive patient software used in hospitals. “I want to help align technology, policy and patient engagement,” he says. “The environment is chaotic and I hope will not be distracted from the patient.”
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