EMR Replacement

HealthIT CIO Interview Series – Mathew Gaug, Lima Memorial Hospital

Mathew Gaug, CIO

Mathew Gaug, MSIS, ITMLE, Executive Director, Information Technology, Lima Memorial Hospital

Lima Memorial Health System was founded in 1899 as Lima City Hospital by the citizens of the Lima, Ohio community. The hospital is a not-for-profit health care organization with more than 1,500 employees, and 25 facilities in their 10-county service area in the region. Lima’s CIO, Mathew Gaug, works hard to ensure that technology enables a convenient, efficient and high-quality experience to that same patient community that was originally responsible for the founding of the organization. Like many other healthcare delivery organizations, Lima Memorial is challenged with a non-integrated ambulatory EHR and EMR. As such, driven by its physician community, it is pursuing adoption of Meditech’s web-based ambulatory product to replace eCW. Ultimately, this will offer a streamlined solution to improve provider efficiency and consequently, patient experience, while providing a foundation for additional patient engagement and telehealth services to be offered.

Key Insights

From a historical context, our organization took a best of breed approach where we went MEDITECH for the acute side, but eClinicalWorks for ambulatory practices. We recently embarked on a new strategic direction, where we are looking to consolidate applications and making a patient-centric decision to have only one record across care settings.

An integrated system enhances the historical context, as the ambulatory side wouldn’t necessarily always have access to the acute side. It greatly simplifies things, as there is only one medication, allergy or problem list to maintain. From a provider perspective, harmonization of different nomenclatures isn’t as burdensome.

We rolled out the ideas of a consolidated ambulatory practice, had demos, and evaluated products. We were vigilant in ensuring it was a physician-based decision rather than being driven by IT. Our physicians drove the evaluation as to keep the status quo or to adopt a new workflow and mentality with the technology used to practice medicine.

 A lot of the communities we serve are rural and telehealth will allow for our patients to have better and quicker access to care. Our goal is to have it integrate to our new patient portal, which will make visits for our patients that much more convenient.

Campbell: Tell me a little bit about Lima Memorial, your role within the organization and your background.

 Gaug: Lima Memorial is a community hospital in Northwest Ohio. We have roughly 1500 employees and 25 facilities in 10 county service areas. We are an affiliate of ProMedica, but at the same time we are the furthest south, so we kind of stand on our own when it comes to medical and clinical decisions, and decision-making processes. In terms of my role here, I’ve only been at the organization for about 1 year now. I came to Lima via the Cleveland Clinic as a promotional opportunity. I was looking to spread my wings a little bit, as I’d spent 20 years at the clinic. My formal title is Executive director / CIO, and I have a team of 56+ with everything IT-related rolling up through our group, which includes technology, development, biomed, communications and informatics.

Campbell: Coming from Cleveland Clinic, obviously you come with the perspective of an organization that’s typically on the forefront of healthcare information technology adoption and it’s probably doing some innovative things that may be ahead of what the broader marketplace is doing. In terms of the application portfolio that you manage tell at Lima, can you tell me a bit more about that mix. Namely, the mission-critical applications, the history of those applications within the organization, adoption rates and any optimization you may be pursuing today?

Gaug: Our main application within the hospital today is MEDITECH. We upgraded to 6.15 a month after I started in the organization, and as such, the project was well underway when I got involved. The team did a fantastic job of getting that implemented. From a historical context, our organization took a best of breed approach where we went MEDITECH for the acute side, but eClinicalWorks for ambulatory practices. We recently embarked on a new strategic direction, where we are looking to consolidate applications and making a patient-centric decision to have only one record across care settings. As such, we are looking to adopt a new ambulatory platform with MEDITECH’s web-based ambulatory product. We’re looking to adopt that same mentality and go that way with our platforms.

Campbell: The sentiment of having an integrated, single record is one that has certainly been echoed amongst the CIOs who have participated in this series and given how the MEDITECH web-based ambulatory product has evolved from a UI perspective. It seemingly limits complexity as providers have a familiarity on the acute side and more capabilities can be offer on the ambulatory side based on some of the innovation the web-based ambulatory product has offered with syndromic surveillance, population health management, and facilitation of coordination of care. I’m sure that approach is supported even more so due to MEDITECH’s acute product being well embedded at Lima?

Gaug: The hospital has been on MEDITECH in one for form or another since the first install in 1994. An integrated system enhances the historical context, as the ambulatory side wouldn’t necessarily always have access to the acute side. It greatly simplifies things, as there is only one medication, allergy or problem list to maintain. From a provider perspective, harmonization of different nomenclatures isn’t as burdensome. In addition, the providers no longer have to familiarize with two different user interfaces, workflows, etc. Most importantly, from the patient’s perspective, via the portal, they are provided a comprehensive view of ambulatory and acute visits.

Campbell: Tying into managing multiple applications across care settings, can you touch on provider satisfaction within the organization. Recently KLAS introduced the Arch Collaborative to benchmark provider satisfaction, and the new clinical informatics track at the CHIME Fall Forum was well received as it highlighted provider engagement methodologies. How do you approach provider satisfaction within the organization today?

Gaug: We have a subset of the team from my informatics group that round, visit with and train providers as one of their sole or main responsibilities. We have a 24 hour a day, 7 day a week physician hotline where providers can call and get in touch with one of my team members directly. That goes a long way in terms of provider satisfaction because the last thing we want is a provider being stuck and have it potentially impacting patient care. We are focused on providing exceptional services and response so we avoid problems with technology or issues with the electronic medical record preventing our providers from being able to make clinical decisions. Another thing that we have most recently done is separated the role of Vice President of Medical Affairs and CMIO. It was previously a single role with dual responsibilities, and it has enabled increased energy and focus for the two areas.

When we rolled out the ideas of a consolidated ambulatory practice, had demos, and evaluated products. We were vigilant in ensuring it was a physician-based decision rather than being driven by IT. Our physicians drove the evaluation as to keep the status quo or to adopt a new workflow and mentality with the technology used to practice medicine. I think that’s key with driving the success of any type of implementation of a new application. Ultimately, we want to make sure that as a result of our decision, patient care is more convenient and it’s more efficient for the providers.

Campbell: Great. Thank you for providing some color around that. Let’s talk about population health initiatives within your organization. I imagine rollout of capabilities will be eased in having an integrated platform. That said, what initiatives are taking place today? Do you maintain any chronic disease or wellness registries? Have you evaluated or adopted technology perhaps within Meditech or externally to address the potential need?

Gaug: Thus far, the adoption has been within eClinicalWorks. As such, we are really focused on the future with the Meditech ambulatory application and what capabilities we can introduce with the integration of the two platforms. There are some exciting things that we’re anticipating coming forward, but for the time being we use care navigators and our offices to make sure that our patient scorecards are being maintained and they identify opportunities for intervention.  We also have a physician group that’s within our organization which oversees all population health and care navigators that are going on in the practice today.

Campbell: It sounds like there are some innovative initiatives on the horizon regarding population health management and it should enhance what may be a manual or patchwork process today. I recently read that you achieved EMRAM Stage 6, a recognition that’s bestowed upon hospitals for achieving higher patient safety through improved documentation. Tell me a bit about that clinical documentation improvement initiative.

Gaug: That opportunity manifested itself when we upgraded to Meditech 6.1.5. We made sure that not only were we going through an EMR upgrade, but we also analyze and pursued clinical workflow optimizations. With the testing that was taking place to upgrade MEDITECH, in parallel, we went into all the clinical and ancillary departments, evaluated workflows and implemented improvements. That went a long way to eliminate non-electronic workflows and improve existing workflows as we pursue stage 7 recognition.

Campbell: Related to PHM, are there any initiatives you might be introducing to better engage patients? I recently read an article published on the Lima Memorial website that was more marketing focused, addressing how patients should plan a well visit. What other types of things are you dabbling in regarding telemedicine and telehealth?

Gaug: It’s interesting you bring this up as I recently authored an article on telemedicine’s role in advancing patient care.  One of our primary strategic initiatives in 2018 is to have telehealth and telemedicine capabilities implemented and offered if not in all the practices, at least all the types of specialties we have. Telehealth may not be achieved in every family medicine practice, but we want to have at least one of those practices using telehealth. A lot of the communities we serve are rural and telehealth will allow for our patients to have better and quicker access to care. It will also enable us to offer different services we may not have today. Our goal is to have it integrate to our new patient portal, which will make visits for our patients that much more convenient.

Campbell: Absolutely. It closes the loops they have a comprehensive view of the interactions with their provider to complement the clinical record. That’s the bevy of questions that I had for you. Thank you for sharing your perspective and insights and best of luck to you with the transition.

About Mathew Gaug

Mathew is a highly accomplished IT business professional with more than twenty years of executive experience guiding the strategy and execution of mission-critical technology infrastructure and support for large-scale health service providers. Mathew is experienced and has expertise in integrating newly acquired facilities and establishing system-wide compliant technologies as well as migrating data centers. Serving as Executive Director,  Information Technology at Lima Memorial Hospital, he successfully orchestrated the implementation of multiple technology initiatives, touching every aspect of health care operations, significantly reducing costs and increasing efficiencies within an aggressive time frame. Mathew holds a MS in Information Systems and a BS in Computer Science from Baker College. 

CHIME Fall Forum Interview Series: Shane Pilcher, CIO, Siskin Rehab

Shane Pilcher, CIO

Shane Pilcher, CIO, Siskin Rehab

The role of the Healthcare Chief Information Officer is changing. Shane Pilcher, CIO at Siskin Rehab, knows it’s important to be on the front lines and understand how every aspect of the organization operates. As Siskin’s first CIO, he paved the way for IT to have a place at the executive table, and now he’s finding new ways to make sure all technology is optimized to fully meet physician needs. In this interview, Pilcher discusses reassessing workflows when implementing new technology, why Siskin needs more than an acute-care-based EMR, and how telemedicine is affecting rehab. He also touches on the CHIME CIO code and the true importance of peer-to-peer connections.

Key Insights

It has been a wonderful combination for the organization, as we’ve witnessed significant growth over the past couple years that I’ve been here. IT has helped enable a lot of that growth, as well as invested significant effort eliminating legacy systems and to update and optimize existing systems.

The longer you spend with any EMR, the more invested you get, and the harder it is to make a change. But, while you get invested with customized content, optimized processes, and those types of things, when you decide to make a change, it’s important to not get caught up in trying to take your old system and fit it into the new system.

We need to spend time looking at how we do our business, optimizing those things, and then wrapping technology around that to enable it.

Not only is that information really important, but the peer-to-peer relationships that you create are critical. You cannot put a dollar value on that, it’s priceless.

I’ll also say, a good resource to have a provider that’s totally against the system as well. Through the process of engaging them, getting them involved, and making them a part of the building process, if you turn them into a supporter, you have a huge resource that will then help the other physician population come on board as well. 

In some cases, I would even suggest that the CIO is very close to having to have the same level of vision that a CEO has in an organization because you cannot focus directly on IT, you must understand the organization as a whole with all of its nuances so that you can help lead them and their technology strategy.

Campbell: Coming from a consulting background, and now working on the healthcare delivery end, you bring a unique perspective to the CIO role. Tell me a little more about Siskin, how you came to be an organization and what your role is today.

Pilcher: We are one of the few remaining, independent, inpatient, acute care, rehab hospitals in the country. We’re just under 200 beds and have been established in Chattanooga, Tennessee for 25 years now. We’re one of the primary sources for rehabilitation care in the area. I came to Siskin in July of 2015.  At that point, they had never had a Chief Information Officer, and certainly IT was never part of the Senior Leadership team. It was a fantastic opportunity to take them down a new direction and finally have IT at the table where decisions were being made and strategy was being developed. It has been a wonderful combination for the organization, as we’ve witnessed significant growth over the past couple years that I’ve been here. IT has helped enable a lot of that growth, as well as invested significant effort eliminating legacy systems and to update and optimize existing systems.

Campbell: Very good. If you’ll allow me to inquire, what are the primary clinical systems that you use today within the organization for EMR and potentially care coordination?

Pilcher: We are a McKesson Paragon shop. We’ve had Paragon in place for a little over ten years now. We are actively pursuing a different EMR, and we’ve narrowed it down to a couple of vendors. We expect a significant EMR implementation in our future within the next calendar year, so its exciting times. Paragon covers most of our areas, especially inpatient care coordination, but we also use an outpatient ambulatory EMR called TheraOffice, it’s one of the few out there that is heavily focused on therapy and rehabilitation care.

Campbell: Thank you for providing background and insight into your pending EMR replacement project. You bring a unique perspective, given that you’re a registered respiratory therapist and served in the United States Navy. Given this, tell me a little bit about how that clinical expertise has benefited you in your career and moving into healthcare information technology.

Pilcher: Absolutely. I have definitely had a varied career path. I do things unusually, in most cases, and my career path is evidence of that. I became a respiratory therapist in the Navy. I spent eight years on active duty and thirteen years in the reserves. After coming off of active duty, I joined Erlanger’s Children’s Hospital in Chattanooga and spent a few years there working as a therapist in the pediatric ICU, the neonatal ICU, the ER, and other areas. They had an opening in the IT department. They were just looking for someone with clinical experience that had an interest in Electronic Medical Records and they were willing and open to train that clinical person to build and optimize the system. So, I found my first opportunity in healthcare IT and spent a few years doing that. I then started consulting, and spent about fifteen years doing that. I was doing all sort of projects from, initially, EMR implementations, optimizations, through strategic planning and interim leadership.

Campbell: That reminds me of the career of Dr. Dale Sanders from Health Catalyst. I attended the Healthcare Analytics Summit a few years back and he talked about applying his diverse career, including command posts at the US Air Force, and how that military background can serve some purpose in offering structure to, what can be, a very overwhelming healthcare IT space, so thank you for that.

Can you tell me a little about any IP you have invested in Paragon today? I imagine having it in place for ten years there may be some technical debt in that system in terms of, perhaps, clinical rules, or documentation. If you could elaborate on the challenges of cataloging those different types of IP in systems as you plan on moving. A lot of healthcare delivery organizations today are moving from a system that is more comprehensive to an Epic or a Cerner, and I assume that is part of your decision making process.

Pilcher: Certainly. The longer you spend with any EMR, the more invested you get, and the harder it is to make a change. But, while you get invested with customized content, optimized processes, and those types of things, when you decide to make a change, it’s important to not get caught up in trying to take your old system fit it into the new system. It’s a beneficial opportunity to be able to reassess what you’ve been using for that period of time and determine if that’s really what you want to bring forward. It also allows for evaluation of established clinical workflows that you’re wrapping technology around. One of the key mistakes that organizations have made for the projects that I’ve been a part of, and even here if we’re not careful, is we try to take a current process and wrap technology around it. If the process and workflow is flawed, or inefficient, we’re just going to exacerbate that and make it worse. We need to spend time looking at how we do our business, optimizing those things, and then wrapping technology around that to enable it.

With Paragon, we have a lot of customized content in it, a lot of our assessments are there. However, because of our unique situation, we are McKesson’s only rehab client, at least up until the last year—I think they got a smaller rehab client that they’ve implemented Paragon with. So, while we have required functionality that Paragon provides us, based on CMS’s Data Regulatory Requirement feature, additional functionality really hasn’t materialized in the last ten years. We’ve had to do a lot of manual processes outside of the system to be able to overcome those gaps. While we have a lot invested in the system, it’s going to be easier for us to make that move than other hospitals only because we’ve had to do so many things outside of the system or used bolt-on third party applications to try and overcome some of the limitations within the system. Now we’re looking for systems with predefined rehab content. We don’t anticipate getting into a situation where we’re the only rehab client that the vendor has, where they don’t have specific functionalities for rehab. That’s due to the fact that while we’re an acute care hospital, we’re also rehab, and we don’t do everything like an acute care hospital does; we need something more than just an acute-care focused EMR.

Campbell: Thank you for elaborating on that. Switching gears, a little bit, can you tell me about your payer base in your market blend, and how that may be unique?

Pilcher: We’re very heavy with Medicare/Medicaid, quite a few of our patients fall into that bucket. We have a variety of other insurance providers, partnerships with organizations as well, for their workman’s comp and other injuries.

Campbell: Is there a good mix of value-based payment occurring, specifically with Medicare Advantage? If so, I imagine there might be a focus for you on HCC – hierarchical condition categories.

Pilcher: I see there being more opportunity. We partner with a few of our referral sources and their value-based programs, but as far as specifically, that’s about the only impact that has with us. Due to our payer process we get daily stipends, if you will, a certain amount of reimbursement per day from our commercial insurance partners and from Medicare. A lot of the value-based purchasing efforts in the acute care hospitals aren’t directly impacting us except as we partner with them to provide care to fit into their value-based purchasing programs.

Campbell: Tying into that, you have a state of the art facility that provides treatment for brain injury and stroke. Do you have any initiatives in place for shifting some of that rehab to home rehab, or incorporating telemedicine, or perhaps patient centered medical home? If so, can you elaborate on that?

Pilcher: The type of patients and the overall population that are presenting to inpatient acute rehab as well as our subacute rehab, is drastically changing. The typical orthopedic patients are being shifted to home health and outpatient therapies, and we’re there to help with that. Inpatient wise, we’re seeing patients with higher and higher acuity levels; they’re sicker than they’ve ever been and require a lot more care. While a lot of the orthopedic and nonmedically significant care is being shifted to home health, our focus has been to ramp up our brain injury, stroke, and neuro programs, as we’re seeing a significant increase in demand for that.  Also, we have patients coming in directly from the ICU requiring rehab, so we’re seeing sicker patients, and many of those that are not being shifted towards the home health and outpatient environment.

Campbell: Thanks for elaborating on that. That’s a very compelling point, you are acute care so obviously you’re going to deal with those who have an inpatient stay. With that said, is it mainly limited to the surrounding areas or do you get out-of-state patients who seek you out because you’re a center of excellence?

Pilcher: We do have patients who come from across the country. The majority of our patients are locally and regionally based. We get referrals from as far as Nashville and Birmingham, but most of our patient population is more local than that.

Campbell: Shifting gears again, what pop health initiatives are in place today? Do you have any care coordination that’s occurring between the acute care setting and home health, easing those transitions of care? Are there initiatives in terms of referrals and/or handing off your portion of the patient record, perhaps through an HIE or any other means?

Pilcher: All of that is in transition at the moment. We have some coordination with our two largest referral sources, the two largest hospitals in the area. They have some specific population health initiatives that we factor in with some of their patients. For some of the orthopedic patients that are not candidates to be discharged, we have programs with organizations to bring them into our organization. As far as very formal sharing of information, that’s not happening much in this area yet, but our two largest referral sources are in the process. One just went live with a new EMR that would give them that ability, and another one is planning on doing it shortly and would change out their system to a system that would support sharing of data. Then, of course, with ours, that’s a key component to whatever system we put into place, to greatly enhance the sharing of data in our area. As far as a formal HIE, that’s not present.

Campbell: Great. I want to touch on your experience at CHIME as well, and gather some of your impressions from it. I know I personally valued the new clinical informatics track this year, which focused on the topic of physician efficiency and engagement. If you could elaborate on your goals with going to CHIME and how you may approach EMR replacement based upon things you may have learned at CHIME, specifically getting clinicians to use a new system and learning the nuances of that.

Pilcher: I think CHIME is an invaluable resource to CIOs in our market space. I was actually part of the planning committee for the fall forum this year, so I’m very pleased to hear that you liked what you saw. We spent a lot of time trying to make sure that the educational content contained value and I certainly think it did. Not only is that information really important, but the peer-to-peer relationships that you create are critical. You cannot put a dollar value on that, it’s priceless. It’s those individuals that are willing to take your call at a moment’s notice so you can bounce an idea off them, and determine how they handled things. When I was transitioning from the consulting side to the CIO role, there were numerous CHIME members that I had developed relationships with over the years, and they were readily available for me to call at any time—and believe me I did—to be able to get advice from. That’s something that, while we get hundreds of calls a day, and can’t take them all, if a CHIME member calls another CHIME member, that call is usually taken. I really value that with our fellow CHIME members.

Being able to get information on how they engaged their clinicians is key because, as we know, that’s not an easy population to have completely adopt an EMR platform, and having them engaged is critical. My advice is that engaging clinicians from the beginning, early on, and frequently throughout the process is a key piece to that adoption. They have to understand that the EMR doesn’t always bring efficiencies, like it was once touted. In some cases there are some, but it usually takes physicians longer to do what they need to do versus when they did it on paper. Understanding why we’re doing it, the safety implications that come from it, and then making sure that they’re part of the process of designing the system that they’re going to use is key. Finding a physician who is leaning towards being able to use the system well is a good resource to have. I’ll also say, a good resource to have is a provider that’s totally against the system as well. Through the process of engaging them, getting them involved, and making them a part of the building process, if you turn them into a supporter, you have a huge resource that will then help the other physician population come on board as well.

Campbell: That’s a great point, to focus on those outliers and not necessarily the low hanging fruit. I agree with your sentiment around CHIME, and kudos to a job well done coordinating that event. Like I mentioned, I witnessed CIOs who are always so gracious with their time. There’s just a deep amount of trust built up among peers and that’s invaluable especially when you’re in a tough position. As you mentioned, the healthcare CIO position today has morphed, as they are the quarterback and the glue within the organization to tie information technology to administration to. I’ll also mention too that the session Bryan Bliven and Dr. Tom Silva from Missouri Health presented was profound. They shared key insights with the way they engaged physicians, making sure that there’s rounding occurring, ensuring there’s -training that is occurring right across from the break room. Those pragmatic and novel approaches were well received.

Pilcher: I completely agree with you on the rounding part. As a CIO, you cannot stay hidden. You have to spend your time out there and that’s where you are able to develop a lot of trust with your end users and not just your senior leadership team. It can be kind of scary and dangerous to get out there because you’re going to hear what doesn’t work, but if you’re committed to getting it fixed, rounding is huge. Just to follow-up on what you were saying, as far as the transitioning of the CIO role, I know a lot of those educational tracks dealt with the transitioning of the CIO and the role we play. In my opinion we are one of the few leaders on the senior leadership team that truly has to understand every business sector of our organization, every business line – understand what they do, how they do it, why they do it, where their pain points are – so that we can then help them put technology around that. In some cases, I would even suggest that the CIO is very close to having to have the same level of vision that a CEO has in an organization because you cannot focus directly on IT, you must understand the organization as a whole with all of its nuances so that you can help lead them and their technology strategy.

Campbell: Absolutely. It must be multidisciplinary, and you must be able to fortify partnerships with your clinician peers. Thank you for sharing these cogent insights and for providing sage advice.

About Shane Pilcher

Shane has more than 25 years of healthcare and healthcare IT experience. He brings to Siskin Hospital his strong healthcare, military and corporate experience in leading teams to align IS strategy with corporate strategic plans.

Shane became a Registered Respiratory Therapist in 1995 while in the United States Navy where he served as a Respiratory Therapist, Navy Corpsman and EMT. In 2003, he converted to an Intelligence Specialist where he served time in Iraq and was the leading Chief over the Naval Intelligence Reserve Region Southeast’s Reserve Intelligence Training program. Shane retired as a Chief from the United States Navy with more than 20 years of active and reserve service. He has also received his Fellowship designation from Healthcare Information and Management Systems Society and holds a BS in Business Administration.

 

CHIME Fall Forum Interview Series: Susan Carman, CIO, United Health Services

susan-morreale-cio

Susan Carman, CIO, United Health Services

Susan Carman is no stranger to the fast-paced change of the healthcare IT world. United Health Services, where Carman is currently CIO, is in the process of overhauling their IT strategic plan, including a potential replacement of their best of breed EMR/EHR for an enterprise solution. Since the current inpatient EMR was only implemented 3 years ago, Carman is faced with the tough decision of yet another system replacement, both from a fiscal and employee fatigue point-of-view. She discusses the implications behind their review of the enterprise; why being best of breed and having a data warehouse doesn’t always jive; and her key takeaways from CHIME.  She also provides sage advice to those startups and digital health organizations trying to get their solutions in front of healthcare IT decision makers.

CHIME Fall CIO Forum provides valuable education programming, tailored specifically to meet the needs of CIOs and other healthcare IT executives. Justin Campbell, of Galen Healthcare Solutions, had the opportunity to attend this year’s forum and interview CIOs from all over the country. Here is the next interview in the series:

Key Insights

When I first came in about a year ago, there was no true inventory of applications. We used a number of avenues to figure out exactly how many we actually had.

We’re a best of breed shop, the kind you don’t see much of any more. It’s causing us a lot of issues because we have about 200 interfaces running information back and forth. It’s very resource intensive and expensive to run.

We’re trying to figure out if we can connect directly to our data warehouse as opposed to connecting to the source systems directly. That’s a big question mark for us right now.

With this information the IT governance team decided that the best approach was to develop a 3 to 5-year Strategic Plan.  The most important component of that plan was to decide on a future EMR roadmap.  Our biggest challenge is meeting our integration goals but doing it in a fiscally responsible manner.

Sitting around the table with other CIOs—gathering the information about where they’re at with their application portfolio, best practices, and things of that sort—was immensely helpful to me. I think it’s mutually beneficial because clearly the vendors are doing this to get some information for their business.

Campbell: Can you give me a little background about you and your organization?

Carman: We have about 380 physicians, 4 hospitals – 2 of which have over 200 beds – 2 smaller hospitals, and 62 clinics.  One of the biggest things we’re working on is our IT strategic plan, so a lot of the questions I’ll be answering today will, unfortunately, be changing over the next year or two.

Campbell: No problem, that’s to be expected. Along the lines of the strategic plan, how many applications does the organization have within the portfolio and how do you manage those today? Do you have an enterprise portfolio management system or is it managed by spreadsheet?

Carman: That’s a great question and going back to talking about being in a state of transition, this is something we’re working on, and spending a lot of time on right now. We have approximately 175 applications that we run. When I first came in about a year ago, there was no true inventory of those applications. We used a number of avenues to figure out exactly how many we actually had. It was sort of an unknown, but I certainly knew there was quite a few of them.

We’re a best of breed shop, the kind you don’t see much of any more. It’s causing us a lot of issues because we have about 200 interfaces running information back and forth. It’s very resource intensive and expensive to run. The application portfolio is basically being kept on a spreadsheet.

Another initiative we’re going to be starting next year is we’re purchasing an ITSM system. A lot of our application portfolio should be kept in that system once it’s implemented rather than keeping it on a spreadsheet. We’re bringing in a consulting company for the first half of next year to help us work on adopting ITIL best practices. The implementation of the ITSM system will be about midway 2017. We’re hoping for some great things as far as doing a better job of keeping track of our applications, providing better customer service, and improved change management.  The last step will be application rationalization to sunset and retire anything that we no longer need.

Campbell: Very good, and speaking of application rationalization, do you leverage an archival solution today? Do you have a data warehouse that it’s shipped off to? Or are you simply taking a copy of the database and storing it on your servers? Could you elaborate on that topic?

Carman:  The business intelligence and analytics software is overseen by the CMIO at UHS.  It is not part of the Information Services department.  Our CMIO is not only a practicing cardiologist, he is an expert in the development of applications and business intelligence. A lot of what we have at UHS is homegrown.  We have a separate Business Intelligence department. We utilize a lot of students from Binghamton University that are working toward their Master’s degree or PhD and need a real life project. We do have a data warehouse.  We are striving to get to a point where our data warehouse is our one true source of information.  We are currently working on our data accuracy via a new data governance model.

Campbell: Right, a lot of organizations are dealing with that, those point solutions, especially if you’re best of breed. How do you integrate that ETL process with the data warehouse?

Carman: We just purchased Watson Health as a population health solution, and we’re going to be implementing that next year as well.  We’re trying to figure out if we can connect directly to our data warehouse as opposed to connecting to the source systems directly. That’s a big question mark for us right now. This would require ensuring all the data is accurate before it gets into the data warehouse and that all of the data is being sent and in a timely fashion.  We don’t have all the data normalized and some things don’t go to the data warehouse at all for various reasons. Sometimes it’s limitations of the applications, but there’s a variety of reasons why not everything is going there right now. We would like to avoid connecting to every source database but we will likely have no other choice.

Campbell: I can appreciate that. You want that data warehouse to serve as the hub, but oftentimes there may be data that’s missing in the ETL process from the source system. I know you spoke of potential replacement of the EMR/EHR. How long has the organization been on the current EMR on the inpatient side and the EMR on the outpatient side?

Carman: We’ve been on NextGen for 12 years and it has outlived its usefulness. It is no longer supporting our physicians in an efficient manner. It’s come to a point where the writing is on the wall with NextGen. We need an ambulatory information system that is more adaptable to the differences in our specialty practices.

As far as the inpatient side, it’s only been 3 years since Soarian was implemented. Now of course we got the bad news that Cerner is only going to support the Soarian Clinicals for 5 more years and we’re 2 years into that.  When I first came on-board, one of the things I was charged with was to survey the ambulatory information system and gather information from the physicians as to whether they wanted to enhance the current system or replace it. Overwhelmingly they wanted to replace the current system.  Since we had just gotten word from Cerner that Soarian Clinicals would only be supported for a maximum of 5 more years, it made sense to review our entire enterprise. With this information the IT governance team decided that the best approach was to develop a 3 to 5 year Strategic Plan.  The most important component of that plan was to decide on a future EMR roadmap.  Our biggest challenge is meeting our integration goals but doing it in a fiscally responsible manner.

Campbell: Right and, to share with you, that’s the sentiment I heard from several folks while at CHIME. There’s just a lot of ‘where’s the money coming from?’ ‘Sure the organization wants to invest in a new application or maybe replace the EMR, but show me how we’re going to be solvent in whole once we do that.’

Carman:   Our Senior Leadership team mostly agreed that we need a fully integrated solution.  Our first step in that process is an EMR Financial Feasibility study.  We need to see exactly what we are up against when it comes to total cost of ownership.

Campbell: Shifting gears to CHIME, tell me about your experience. What did you look get out of it? What were some of the things you appreciate about the event?

Carman: I loved it. I can say overall, I thought it was fantastic. I got more out of the focus groups than anything else. Sitting around the table with other CIOs—gathering the information about where they’re at with their application portfolio, best practices, and things of that sort—was immensely helpful to me. I think it’s mutually beneficial because clearly the vendors are doing this to get some information for their business. Out of the entire week, that was where I felt I got the most information.

I certainly had a lot of questions about converting to an enterprise wide solution from best of breed, I spoke to a lot of different people about their situation. I even spoke to the #3 person at Cerner about customers who have transitioned from Soarian to Cerner.   I left there with a good feeling that we were performing the correct analysis. It was a great validation for me, and a very worthwhile trip.

Campbell: That’s excellent to hear. Aside from the networking aspect, like you said, you’re able to test hypotheses and synthesize strategies. Perhaps you could offer some insight to our audience at Health IT & mHealth, which is primarily focused on startups and digital health companies – a market that is overwhelmed by patient engagement solutions. For your organization that’s traditionally been best of breed, and maybe looking to an enterprise wide solution, tell me a little bit about how you would ever consider a digital health startup solution? What would be your criteria for evaluating that?

Carman: Target what the bigger companies don’t have or don’t do well. I think what you’re going to see is, if you’ve got a Cerner or an Epic Enterprise solution and they’re selling that same product, you’re not going to win because CIOs will gravitate toward their core vendor. They want to just go to one person; they don’t want to have numerous vendors that they have to deal with on a daily basis because it takes up so much time for a CIO. If there’s some sort of niche that you can find, where the vendor has either done a lousy job of providing the solution or they don’t do it at all – and certainly Epic has several things that they don’t do – concentrate on those areas. When you’re coming to the table you can say ‘look, you don’t have this currently, you’re not able to get it from your core vendor, and we have a great solution.’ I think that’s how you get CIOs to listen to you.

Another piece of advice I would give is always come to the table with how you’re going to make that CIOs life easier. First and foremost, what are you going to do to solve the problem that organization is experiencing?  Investigate who is in need of the solution before you go and invest your time.  Make sure to target your audience in that way. I get dozens and dozens of emails a day about things that aren’t relevant to me.  I think, ‘goodness these people are wasting a lot of time, I’m not responding and so on and so forth’. I think a lot of the smaller vendors need to do a better job of targeting their audience. Every now and then I get an email and I say ‘hey you know what I am going to respond. I don’t normally respond, but this person really got my attention, it’s something I need, they clearly understood my business here and what we do.’ It wasn’t a generic email.

Campbell: That’s a great point and great advice for anyone in the space. Any other closing thoughts you wanted to offer around the CHIME event or any organizational newsworthy items?

Carman: At this point, one of the big things we are grappling with, is what do we do with MACRA and MIPS and how do we transition. There’s no more PQRS, and MU is fading away. It’s a big question mark for us, and now with the new administration coming into play I think we’re all kind of scratching our heads saying ‘what does that mean for healthcare IT?’ With Obamacare up in the air, I’m sure a lot of CIOs are sitting back and saying ‘does that effect MACRA, MIPS, and everything else coming down the pipeline? What’s going to change?’

CHIME Fall Forum Interview Series: Daniel Morreale, Senior Vice President/CIO, Hunterdon Healthcare System

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Daniel Morreale, Senior Vice President/CIO, Hunterdon Healthcare System

Consolidation is big on the mind of the CIO Daniel Morreale, of Hunterdon Healthcare System. After inheriting the multi-system environment two years ago, he has been evaluating a rip and replace initiative, moving to one core system. That’s not the only change Morreale hopes to make at the healthcare system. He’s inspired by the world of social media and the connections it can extend. In this interview, Morreale talks about the “membership model” for healthcare he’s looking to implement; the ups and downs of data archival and storage; and Hunterdon’s current data governance strategy. He also shares his personal predictions for the future of healthcare and bringing the focus away from the toys and back to the people.

Be sure to register for an upcoming healthsystemCIO.com All Stars Panel Daniel is participating in on January 19th: “How to Ensure Your Business Continuity/Disaster Recovery Plan is HIPAA Compliant.”

CHIME Fall CIO Forum provides valuable education programming, tailored specifically to meet the needs of CIOs and other healthcare IT executives. Justin Campbell, of Galen Healthcare Solutions, had the opportunity to attend this year’s forum and interview CIOs from all over the country. Here is the next interview in the series:

Key Insights

If you’re in my system longitudinally, can I get rid of those lab results you had 8 years ago? No, and I think that’s a problem.

Then again we have to ask ourselves, how long do we keep our EMRs and is anybody running an EMR they were running 20 years ago? Chances are no.

But then in the event of legal action, if I have it I have to produce it, it’s discoverable. I would rather only present for discovery that which I’m required to present for discovery. If the data had been purged by policy and no longer there then I’m no longer responsible for producing it.

Most health systems tend to grow by buying physician practices or expanding their market, which is a pretty traditional means of doing that work. However, I think an extraordinarily strong mobile presence and web presence can start to attract the 20 and 30 year olds who aren’t really using healthcare now, who I want if I’m in a shared risk environment.

At the end of the day I’m doing healthcare and that’s about people. How do I make the experience easy for you and me, or family, and deliver quality, convenience, and access?

Campbell: Let’s start with a little background. Tell me about your organization and your responsibilities.

Morreale: Hunterdon Healthcare is the only hospital in the county, [located in Northwest New Jersey]. It was started in 1956, in an effort to improve the health of the population and community. As an organization we kind of have a 60-year head start on population health. It’s still a standalone facility, we have just under 200 inpatient beds, and do just under a million ambulatory visits a year.

Campbell: What are some of the initiatives you’re working on right now? What are some of the reasons that drove you to CHIME in terms of the learnings you expect to hear from your peers?

Morreale: The initiatives we’re working on in the healthcare system right now are dedicated to two propositions. One is to improve usability; how do I make the variety of systems we have more user friendly? And secondly, a consolidation effort; looking across our vast number of software tools and trying to consolidate them. Prior to my arrival at Hunterdon two years ago, every department bought whatever they wanted. As a result, I have 5 document management systems, 6 faxing software applications, etc. We’re trying to consolidate and replace with enterprise level tools when we can. Next year we’re going to start doing core replacements around our financial systems, and that’s going to be a rip and replace. We’re planning an initiative around creating an access center, i.e. one telephone call to concierge level service with the health system.

Campbell: Tell me a little about where archival fits into this. With the systems you look to replace, have you gone through that evaluation of migrating versus archiving?

Morreale: We have not, and for several reasons: A majority of the healthcare tools that are out there don’t have a good process for archiving, deleting, or massaging patient records, at least at the patient level, which is always a challenge. However, we do have criteria for retaining data, predicated on state and federal mandates. Right now everything is in a tiered data structure. Our more transactional data is on a state drive, our deeper archival data is on EMC, some IBM storage in the middle, but my intent is to go pure solid state. This will add cost, but increase retrieval speed and simplify the environment. But even in that environment I’m just continually adding and saving data. I’m never really deleting anything. So there are records that are 25 years old, that I no longer need, and I have no means of getting rid of them.

Campbell: Have you evaluated any archival solutions that are healthcare specific? Tell me about the challenges you see in the vendor marketplace for archival solutions.

Morreale: Well on the technology side, I think there’s a wealth of tools, but their weakness is in the healthcare applications. In my EMR I do not have the capacity to delete a record. I absolutely do not have the capacity to delete part of a record. If you’re in my system longitudinally, can I get rid of those lab results you had 8 years ago? No, and I think that’s a problem. It costs me money to store it, manage it and keep it secure. But then in the event of legal action, if I have it I have to produce it, it’s discoverable. I would rather only present for discovery that which I’m required to present for discovery. If the data had been purged by policy and no longer there then I’m no longer responsible for producing it.

Campbell: As part of the overall portfolio strategy, do you see yourself consolidating applications and migrating from one EMR to another?

Morreale: Eventually I think we’re going to have to, and we’re targeting 2020 or 2021 as the year to make that jump. That is my opportunity, and only opportunity, to clear records.

Campbell: Is there hope that in that time there are some advancements made?

Morreale: I think it would be nice, but I don’t see it happening, I don’t hear any vendors talking about providing tools that do that. Then again we have to ask ourselves, how long do we keep our EMRs and is anybody running an EMR they were running 20 years ago? Chances are no. I think over that course of time we generally take all we can from a product and at some point we start looking for additional functionalities, newer user interfaces, and more bells & whistles

Campbell: Shifting gears, what is your data governance strategy within the organization?

Morreale: Data governance is pretty straight forward. We have our applications tiered for priority, and as a result of that, the data is tiered. We ask the primary departments to be the titular owner of that data, in that the patient is the real owner. We look at IT services as being the police – the ones who stores it, protects it and keeps it under lock and key. When there is a challenge around data, it always manifests in reports: what is the length of stay in system A, is it not the same as in system B? With great effort, a year ago, we undertook building out a data dictionary. To this regard, I know that when I’m using field MX4233 in my EHR, I know it’s a patient address and that it is defined in this way. Then we’ve carried that across to the other clinical systems that have that data. It is by no means complete, it’s a continuous effort, and it’s massive with the 160 different systems. We really concentrated on those items that people are regularly reporting on. As such, when I produce an end of day admission report in system A it’s also the same in system B.

Campbell: What’s the vehicle or mechanism that you’re using?

Morreale: This is one of the examples where we built our own tool. We went out and created a data lake: we’re taking a snap shot of the data, putting in the data lake, normalizing it, and then consolidating all our reporting out of the data lake. So, at least my reports are more consistent than they were prior.

Campbell: Where do you see an opportunity for innovators in the vendor space?

Morreale: I think there’s opportunities in home health, which is pretty much owned by a few big companies with technology that’s a little dated.

I think there is a whole field of healthcare to be discovered in social media. How do we capture that? How do we integrate into that world? How do we use that to attract future patients? Most health systems tend to grow by buying physician practices or expanding their market, which is a pretty traditional means of doing that work. However, I think an extraordinarily strong mobile presence and web presence can start to attract the 20 and 30 year olds who aren’t really using healthcare now, who I want if I’m in a shared risk environment. Use that as a tool to create that sticky relationship between you and my health system so that when you do need our services, we’re the natural choice.

I think the value proposition around that has to be very high, but it’s certainly difficult to compute. We’re putting a lot of effort into that arena. My development team is looking at creating what we’re calling a ‘membership model’ for the health system.  It’s essentially taking the concepts around Netflix and American Express: you become a member, and incorporate that into how I deliver care. If I can convince you to be a member, I can give you one telephone call scheduling; I can stop leakage out of my physician offices by scheduling your next appointment as you’re walking out the door; or schedule that x-ray or that minor surgery you might need. I can broadcast educational information to your mobile or home device. I can create social platforms for you to talk to other people with your disease state. I can do all of those things as a background product, but at the same point I’m creating that sticky relationship between you and my health system.

We’re also looking at integrating wearable data. We are fortunate enough to be the in the healthiest and wealthiest county in New Jersey, so we think there’s the capacity to offer the service to our community: let us monitor your Fitbit or your wearable device data, tell you how you’re doing on your health effort, and give you an opportunity to earn points. We have a points program in our membership model – buying broccoli instead of bread; going to the gym –  those sort of things. And I think that kind of stuff is going to be more of my future than buying physician offices.

Campbell: There seems to be a diminishing return there or rather a saturation to that model.

Morreale: I think so. How many physician offices can you have in a community? How far can your reach go? If I’m doing it through mobile and social media, my reach is greater. I’m not limited to 20 miles or 25 miles. I can be attracting or engaging people who are 50-60 miles away. I can help you take care of your parents who live in Phoenix or back in Boston, I can do all of those kinds of things. We think there’s some potential there. It’s going to be one of our big investments in 2017 – to further define that model and see if we can make it fly.

Campbell: Certainly enlightening and inspiring.

Morreale: I think it’s just a different way of looking at what we do. I don’t like to get caught up in the technology. I know a lot of CIOs who get caught up in the technology and the toys, and the toys are cool. I mean let’s face it, but at the end of the day I’m doing healthcare, and that’s about people.  How do I make the experience easy for you and me, or family, and deliver quality, convenience, and access? I think that’s where a large portion of our future has to be.

This interview has been edited and condensed.

About Daniel Morreale
Daniel Morreale is CIO at Hunterdon Healthcare, a community hospital based in central New Jersey. He has held CIO roles at a number of organizations, including Riverside Healthcare System, Kingsbrook Health System, and Atlanticare. A CHIME fellow, Morreale was the recipient of CHIME’s’ Innovator of the Year’ and ‘Collaboration of the Year’ Awards, and was recognized by Computerworld Magazine as one of the ‘Premier 100 IT Leaders.’ He also received the Safety Net Award from the National Association of Public Hospitals, and the Smithsonian Center of Innovative Technology Honors Laureate Award. Morreale is past-President of the New Jersey Chapter of HIMSS.

About Justin Campbell
Justin is Vice President, Strategy, at Galen Healthcare Solutions. He is responsible for market intelligence, segmentation, business and market development and competitive strategy. Justin has been consulting in Health IT for over 10 years, guiding clients in the implementation, integration and optimization of clinical systems. He has been on the front lines of system replacement and data migration and is passionate about advancing interoperability in healthcare and harnessing analytical insights to realize improvements in patient care. Justin can be found on Twitter at @TJustinCampbell and LinkedIn.