Health IT

CHIME Fall Forum Interview Series: Perry Horner, CIO, Adelante Healthcare

Perry Horner; CIO, Adelante Healthcare

Perry Horner; CIO, Adelante Healthcare

As a CIO of major healthcare system, one of the most important lessons Perry Horner learned was when he found himself personally forced into the complicated world of connected health. With his new motto of ‘keep it simple,’ Horner is taking on the connected health world full force, implementing new and affordable technologies, always looking three years ahead. In this interview, Horner talks about Adelante’s EHR transition from Vista to Nextgen; his data governance strategy; and what he’s looking for in a practice management system solution. He also discusses his compelling personal story with the healthcare system and the improvements he’s pushing for to make solutions simpler and more affordable to all.

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 first interview in the series:

Key Insights

I never used to be an agile project management style person, but over time I’ve changed and I see the same thing with software. Gone are the large monolithic products, where they do everything. Stick with your core competencies. If you’re doing something well, partner with someone who’s doing the other part well. Make one conglomerate product. That’s where I’m hoping to see things go.

I was in the ICU for 10 days, and when I got out I had 5 months to recover before I could go back to work. During those 5 months I went through the ringer as far as what a patient experiences, and I was taking notes. Mental notes and physical notes as to what I was seeing, how things were being treated, keeping a focus on technology. When I got back, I wrote a 5-year plan for Adelante and I infused into it what is now called “Connected Health”.

I’m tired of hearing “I have an app for that.” I’m experiencing app overload. I’m kind of reversing thoughts, back to making it simple.

Forget about trying to capture the whole supply chain. Find your place on the supply chain and just focus on it. Do the best you can there.

Campbell: Let’s start with a little background. I saw that you actually come from the vendor side, that’s probably a helpful perspective to have when working for a provider organization. Tell me a little about yourself and where you’re working at now.

Horner: In my previous life I spent 17 years at ASU, I was the Head of the Library Systems, Technology Support and Development department. I jumped into healthcare with Adelante Healthcare because they intrigued me with a position opening, a Linux network administrator—which there is no such thing, so I was curious about what they were doing. The CEO immediately gave me an offer to head the entire technology operation there so I took that.

I inherited their EHR at the time. At that time Adelante had 7 locations. The first site they brought up using the open sourced version of the VA Vista EHR, and with the success of launching that site, we received a HRSA HIT Rapid Grant. Two Grants actually: one to form a HCCN, and the other to implement an EHR for all those members. Two other community health centers joined us and we became an HCCN and implemented Vista for all of them including Adelante, which was a member of HCCN. I was then hired by the network, which was called the Community Health Open Source Network, as their CIO. I hired three others and we developed out our support department for all the members. That lasted 18 months and then our largest contributing member pulled out and it was not sustainable anymore, so we decommissioned everything.

Adelante Healthcare was on Vista and I knew we could do better, even though as a technologist I was in love with the Vista system. It’s a MUMPs database, which is basically a flat file database, beautifully written, I’m amazed at it. As far as the end product and the application, for us, there was a little of the square peg round hole that had taken place. When Meaningful Use, the whole Accountable Care Act, etc, came about, Vista kind of squeaked by. My crystal ball said that this is going to give us problems all the way down the road with stage 1,2,3, and having to actually develop all the little kludges around it, because there are no companies that are doing it. So I started a sunset on Vista and we RFP’ed for a new EHR.  We settled on NextGen as our EHR.

Before my time, when they were working on implementing the first site with Vista, it was done in a garage development style. The EHR that Adelante was using included traces of experimentation from the beginning and there wasn’t a demo or learning system created. So both the CMO and myself were not comfortable with bringing over the data into NextGen. Instead, we transferred over about 12 key demographics for each patient over into NextGen and left the entire chart in Vista. For the next year, providers would go back to Vista when they saw a patient that had a NextGen record and extract certain elements out of their chart and put them into NextGen. The whole patient cycle included about 38,000 unique patients.

When that was done we started on the sunset project for Vista. It was too expensive and cumbersome to maintain the operational server. So I had to get all that data out of there and into a system diagnostics machine-readable format. I wanted everything to be indexed using four different identifiers, so you could do reverse look-ups using: date of birth, last name, social security number, and the medical record number. I wanted the format to be in discrete XML – specially in a CCD format. Every single patient record needed its own directory with sub-directories of all the imaging data and any other files. We needed two formats: the XML and then a presentation mode – everything in a PDF. In order to accomplish this, I contracted with a programmer, who over two years, finalized the extraction. Vista is so complex with its filing system hierarchy within that database. The referencing and finding the linkage of every piece of that patient’s record was challenging, as it’s scattered everywhere.  I was quite impressed that we were 100% able to extract everything, reformat it and make it useable.

That was our EHR at that time. At that time too, our practice management system was GE Centricity Practice Solutions, so there’s my next project next year, getting that data out. Luckily that’s a SQL database, much easier than doing it with MUMPS.

Campbell: Tell me a little about data governance in your organization and how that is handled

Horner: We’ve got a plan for 2017: creating an information governance committee. In the meantime, everything is more specialized—a privacy committee, security committee, the various others around compliance, quality assurance—we want to bring all of that up into the next level of the leadership decision-making body and have an overarching Information Governance Technology Steering Committee.

Campbell: Do you have challenges at all with interdepartmental nomenclature, mapping? How is that handled?

Horner: Very wild-wild west style. We are small enough at the moment where we can still talk to each other and accommodate. Ten years from now we won’t be. We definitely need to have common definitions, common protocols. That’s why in 2017 the information governance will form and set the framework to start development from there. I’m pretty pleased that AHIMA has really taken the lead in producing a lot of resources around information and data governance.

Campbell: And speaking of the portfolio, how many applications do you have in it today? Do you leverage any portfolio management applications or is it small enough where it can be optimized?

Horner: Small enough at the moment.  Right now, except for our HR system and a credentialing application, everything is on premise. In two years, we will have outgrown our corporate headquarters, so we’re building a new facility and this time around we’re not building a data center in it. The project kicks-off in December, and we are slowly migrating hosting out to third party, starting with the low hanging fruit – file services, those type of things – with the EHR at the end.

Campbell: Mission critical applications last.

Horner: Yes, we designed our Mesa Facility as our fail over location, so we do have redundancy there. We’ll continue to use that for fail over but for our primary, we want it in an external data center. And if anything is platform-as-a-service, software-as-a-service, we are always entertaining that. Anything that can accommodate a heterogeneous environment.

Anything that’s HTML5, a no SQL database back-end, that true software-as-a-service environment, that’s what I keep my eye on. Any vendor that’s moving that route, has a product there, is large enough to actually interface with others. I never used to be an agile project management style person, but over time I’ve changed and I see the same thing with software. Gone are the large monolithic products, where they do everything. Stick with your core competencies. If you’re doing something well, partner with someone who’s doing the other part well. Make one conglomerate product. That’s where I’m hoping to see things go.

Campbell: I did some research and saw that there was an initiative, back in May, where you went out for bid with some other organizations for application development

Horner: Yes, that is on the connected health end. That was the Phoenix Chamber of Commerce’s Reverse Pitch for Healthcare. Speaking of connected health, in the beginning of 2014, I went in to see my doctor, who happens to be an Adelante Healthcare provider. My heart was one minute going 160 beats, next minute going 70, just off and on. It was a nuisance to me and it had been doing that for about 4 weeks, during December, during the holidays. She hooked me up to some diagnostics and after about 20 minutes of checking readings, she immediately looked at my wife and said, ‘if he drove, he’s not, you’re driving him straight to the hospital; he’s to be admitted to the ED.’

For the next 48 hours’ things were looking bleak. I was on my last leg. I was feeling fine until that Monday evening when I was in the hospital. My heart was failing – down to 15% capacity, and my family was told I had maybe 48 hours, and to start making preparations. I had a team of twelve different specialists all trying to figure out what was going on, and finally it was a cardiologist who figured it out. It was my adrenal gland. One of them was causing this and he came up with a cocktail that actually worked, stabilized my heart rate and threw me on the road to recovery.

I was in the ICU for 10 days, and when I got out I had 5 months to recover before I could go back to work. During those 5 months I went through the ringer as far as what a patient experiences, and I was taking notes. Mental notes and physical notes as to what I was seeing, how things were being treated, keeping a focus on technology. When I got back, I wrote a 5-year plan for Adelante and I infused into it what is now called “Connected Health”.

I was given a great care plan, things that I had to do at home, and I didn’t have an at home nurse, so that responsibility was given to my wife. She would make sure I was taking my blood pressure every 4 hours, and taking these pills in the morning, these pills in the afternoon, I was walking around for x amount of time, and ensuring I was eating these low salt foods. Two weeks later she was tired of it, she was angry with me, and I was tired of it too. I was then slacking back into a mode where I wasn’t doing everything and my specialists and my PCP weren’t seeing me every other day to monitor. I was on a schedule to come back and they would evaluate me and see what my progress was. I was like “there’s got to be something to keep me motivated and also keep that care team informed early, in case something goes wrong.”

A lot of times providers experiment. You’re on one medication and then they’ll check-in maybe three months later to see if that worked, and if not, it is changed. Now take this medication. Well it didn’t work in the first 72 hours, it’s not going to work for the remaining 90 days. Connected health solves this by having those monitoring and diagnostic devices in the home. It’s nothing new for the hospital world, in fact it’s been around for a while. You get discharged and you take a package home, that’s got a blood pressure cuff, a thermometer, a scale, or whatever, all connected via an app to your phone, to the internet. For me though, knowing how tired and wiped I was from the hospital experience, I cannot see how somebody who wasn’t a CIO would go through the process of connecting all of these devices, having to always spark up a tablet or a phone in order to see readings and do things to communicate. I wanted it to be as simple as possible. For example, with my scale in the bathroom, I could replace it with a connected device whereby, I just set this scale down, I don’t have to program it, do anything to it, I just have to step on it. Everything should be done already. The reading should be able to go back to my provider seamlessly. Same thing with the blood pressure cuff, I just want to press the button and that’s it. Nothing else.

I went to HIMSS Connected Health Conferences, which was really a bunch of developers trying to figure out what’s going to play into this world, with not very many established products yet. I desired a product that was just dirt-simple. For our population, 50% of our patients are on state Medicaid, which means they’re in financial distress. I want our devices to be as [affordable] as possible. It just needs to be what it is. That was my ask. Create this…and there was a company that actually did. Carematix collaborated with Verizon to develop a solution. So now you’ve got your carrier service, and you’ve got your product. The transmission doesn’t go directly to the cloud from the scale. The scale actually communicates to this little hub device that is plugged into the wall or any outlet, hidden away. The patient plugs into the power, steps on the scale, anywhere in the household. They don’t need to program anything, don’t need to worry about it, don’t ever have to remember that they have the little box plugged into the outlet ever again. Everything works and it’s affordable. That was the other piece. Carematix has priced their product at a dollar – a dollar a day per patient. That’s $30 a month for two devices. The cloud based management system, the whole shebang, no carrier fees, nothing – that is everything. So for us, we’re looking at $360 per patient per year. That is sweet. Problem solved.

But I had to wait 2 years for something like that to appear, and none of this is new technology. We’re going to do a pilot for two years now too. We have a control group – same chronic conditions, same age, everything very similar to its pair experimental group. The experimental group gets the devices while tthe control group receives traditional care. Over time we’re going to see if we can improve that patient’s health by early warning, being able to follow up immediately when we see something, and being able to contact that patient to see if we can change something. Improve that health much faster than the traditional way. If so, money well spent. To circle back around to your original question, that’s what that initiative back in May was about.

Campbell: It’s seems you’re well in tune to startups. What learnings did you have with interacting with some of those startups and what advice would you have for folks in those areas that would give them a leg-up or make them more efficient?

Horner: Well for me, I’m getting really jaded. I’m tired of hearing “I have an app for that.” I’m experiencing app overload. I’m kind of reversing thoughts, back to making it simple.

When it comes to solutions, if you can shift the time and complexity away from the end user, make it as simple as possible and most importantly, know and understand your customer. I can’t believe the complexity of some of these devices in connected health that they’re sending home with elderly patients. Really? You’ve got to be kidding me. Keep it simple and affordable.

Forget about trying to capture the whole supply chain. Find your place on the supply chain and just focus on it. Do the best you can there. Play nice with your competitors because the consumer is going to piece-meal their solution together. Apple has done this, but they’ve kept to their own ecosystem, so kind of do like Apple but in an open way. I’m a big open source advocate.

Campbell: Well that’s the topics that I had looked to cover. I appreciate you taking out the time. That personal story you told was so compelling. To me it’s stories like that, where you, the information technology leader for the organization that’s trying to improve that care, has the first hand perspective – a perspective that a majority of the time is lacking

Horner: That was my silver lining. That was my experience and I appreciate having gone through that. Because that was everything, from imaging to lab work up the wazoo, blood work every other day, the diet and dealing with the nutritionist. These providers, they want you to get better and they come up with their plan for you. These people come up with their plan for you, and it’s so much you’re overwhelmed. You were sick and recovering to begin with and then to be burdened with so much stuff to have to do. It’s almost like that’s the formula for you to fail anyway, even with those great intentions behind it. Somethings got to be there, that’s in my house, with me by my side—and it’s not my wife—that will keep me moving along but not somethings that’s going to overwhelm me. It’s got to be simple and easy. Part of my routine in the morning, is getting up, stepping on the scale. I do that already. It represents a great opportunity to capture that data because that’s got clinical implications. For others, there would be other things that they do, maybe someone gets on a StairMaster every day. Well do you hold onto it? Is it capturing your heartrate? Data. Capture it. Use it. Internet-of-Things, where we’ve got devices communicating to devices communicating to devices, intelligently. That’s going to do things. “Oh your heartrate is going up quite a bit, let’s lower the temperature in that room” I didn’t have to do anything. My smart watch already communicated to my smart thermostat and did that for me.

This interview has been edited and condensed.

Boston Google Glass Challenge

Google glass is a ground breaking technology that will revolutionize the way that physicians practice medicine. Last Wednesday April 23rd I was present for the Google Glass Challenge “Final Smack down” at Google in Cambridge, MA. I gained a new appreciation for Google Glass after viewing innovative demos of the new technology and hearing first account experiences of the technology from physicians.

The first speaker, Nayan Jain, Presidential Innovation Fellow told an amusing story that demonstrates how new the technology is and how it is not widespread yet. He spoke about being in a foreign country and how the government officials of that country thought he was a terrorist because he was wearing Google Glass. He said was hoping to show the officials how glass can be utilized for homeland security, but they were unimpressed. In other words, he said “he was lucky to get out with his life and his Google Glass intact”.

Rafael Grossman, a pioneer in medicine, the first physician to use Google Glass during surgery presented next. He started by presenting the shocking figures that 440,000 deaths occur every year from preventable medical errors and 40 times a week wrong side surgery occurs. Google Glass would rectify these hazards by notifying the physician when they were about to perform a medical error. Google Glass would also engineer new medical training techniques as med students would be able to see exactly what the professor was seeing from anywhere in the world instead of the dated method of students watching through a viewing window. Currently, we utilize EHR’s in the same way we did with paper records, clinicians manually put data into the EHR and take it out. Google Glass would allow information to be sent and received from the EHR automatically.

Chris Coburn, VP of Partners Healthcare talked about the upcoming disruption in the field of healthcare. Currently there are 6,000 hospitals but in the coming years there could be 60 or 60,000 hospitals as the delivery of care changes. He said that while healthcare venture is down as is the funding for lab science, a wider range of companies including hospitals are becoming involved in ventures. Hospitals are starting to back technology and having their own investments.

Dr. Karandeep Singh of Brigham and Women’s Hospital explained that, historically providers would query the patient for information about how the patient was doing. However, the invention of EHR’s has changed this interaction. The science of medicine has been preserved, but the art of medicine has been lost as providers now spend most of their time with the patient entering information into the EHR. Google Glass would allow a provider to stay at the patient’s bedside while reviewing information from the EHR and bring back the lost art of medicine. Amazingly, the technology is able to tell where the provider is in the hospital and automatically pull up the patient’s info based on which room the provider is in. Dr. Singh did an exciting demo where he used phrases like “show me the lab results”, “show me the trend for sodium”, “show me the medications”, and “show me the chest x-ray”. All of the commands swiftly provided the information that Dr. Singh had asked for.

Steven Horng from Beth Israel Deaconess Medical Center described how the hospital has employed Google Glass in their workflows. He compared the implementation of Google Glass to the implementation of iPads at BIDC. BIDC went live with iPads immediately after they released which allowed physicians to spend 30 minutes less at their workstations. BIDC went live with Google Glass three weeks after they received Glass and it is expected to decrease time at the workstation even more. Their V1 one of the deployment permitted information retrieval, which included lists of patients, vital signs triage notes, provider information with pictures, comments on what is happening with the patient, medication reconciliation, problem lists and allergies. The purpose of their V2 is to integrate Google Glass with the entire enterprise. This will use machine learning to use all the available data about the patient and determine how sick a person is based on mortality rates.

Google Glass is a very exciting technology that will transform the way doctors practice medicine and utilize their Electronic Health Records. It will allow providers to focus more of their time and attention on the patient which will allow the art of medicine to be reawakened.