ARRA: The Care Revolution (a guest article by Newton-Wellesley Hospital CIO Scott MacLean)

By Scott MacLean

Scott MacLean is CIO of Newton-Wellesley Hospital, a community medical center located in Newton, Mass., that is affiliated with Tufts University School of Medicine and Harvard Medical School. Newton-Wellesley is a member of Boston-based Partners HealthCare, where MacLean serves as corporate director.

Electronic medical records, meaningful use, interoperability — these common terms have been at the forefront of our discourse since the passage of the ARRA recovery act. Many of us, however, have been working on initiatives and struggling with these concepts for years. In our case at Newton-Wellesley, business drivers from our integrated delivery system and associated partnerships have already given us a test run on some of the challenges created by the stimulus incentives. What follows are our examples of underlying disruptive forces and tips we learned for mitigating them.

Changes in Software — Pushing Vendors Our industry is moving from proprietary software and competitive differentiation based on information, to a mandate of interoperability. It will take some time for vendors, providers and payers to respond, but respond we must. Because my facility is part of an integrated delivery system (Partners Healthcare) and other hospitals in our network use different software, we have been seeking this information exchange for some time. For example, we have an enterprise allergy repository. Our internally developed systems utilize this repository natively. If a provider writes an allergy into one system, it displays and can be acted up on in all others. We run a well-established vendor system that often acts as a single source for automating all areas of a hospital. Our allergy requirements were foreign to the vendor, but to their credit, we are working together to meet the clinical goal. We’ve been able to move this forward because we are an influential provider and the looming ARRA requirements were another likely factor in making our vendor interested. We needed to have several conversations with the vendor until they were able to respond in a way that made business sense for them. Be patient. Our network also has a mandate for CPOE and eMAR in all of our acute care facilities. We deployed CPOE in 2006, but ran into some difficulties with eMAR in 2007. Our software supplier recommended that eMAR be deployed before CPOE. Because we had numerous order sets and medication processes, we worked with the vendor to adjust their eMAR product. We believe we helped improve the product for safety, and to meet various regulatory commitments. We delayed our deployment for a year while working with the vendor to make these changes. During this time, the vendor made inquiries of other customers to make sure the product changes would work for them. We also made comparison calls and visits to other hospitals to optimize our processes.

In both cases, our vendor needed to view architectural changes as potential for growth rather than as a threat of lost sales. Consideration of these changes came about because of collaboration and partnership, rather than proprietary protection — for both parties.

Business

Decisions

We have all lived through the hype about RHIOs and interoperability. We have learned that changes in process or software are driven and sustained by business partnerships — or now, by government stimulus. In our case, many of the changes we’ve made have been because of our affiliation with our corporate parent. Last year, we implemented our corporate enterprise resource planning solution. Previously, we had reasonably good processes for HR/payroll, finance and materials management and best of all, we supported these processes inexpensively, especially from a software support standpoint. But business processes and software changed, and staff moved across town. We heard complaints about the change, the bureaucracy and the cost. The truth is, these functions aren’t the core competency of a community hospital. The change gave us more space for clinical functions and allowed the parent corporation to have more efficient standards for materials, human resources and financial measurement.

This year we are the first hospital in our system to install revenue cycle software that will eventually be used throughout the network. More aggressive than the ERP change, the revenue cycle system includes patient-facing processes such as scheduling, registration and billing. Again, in an effort to perform patient administrative functions as efficiently as possible, process standardization, changes in employee location and common software all contribute to increased anxiety in the institution. As leaders, we keep reminding staff that these changes are part of the overall healthcare efficiency solution that will sustain us going forward. Some employees are able to absorb these concepts and adapt more easily than others. We repeatedly coach and support our well-performing employees, particularly in these times of change. For others, their attitude and unwillingness to join the mission cause them to opt out or be terminated.

While we have yet to tackle common clinical systems, we do have some uniformity in our ambulatory record, our clinical data repository and with functions like the allergy database mentioned above. We also have begun to have limited information exchange with a large affiliation of physician practices that has significant admissions to our hospitals. Some of the work we have done for that business relationship has been leveraged to improve internal processes and has motivated people to view patient care as part of a broader continuum.

All of these business relationships require us to view ourselves differently — namely, that we need to collaborate and share rather than protect and keep secrets.

Change in Identity

What does all this mean and what will happen with the ARRA? We all know the hackneyed expressions about change. It’s hard and people don’t like it. As we’ve been through these recent implementations because of our corporate relationship and external business partners, we’ve realized that people have actually had to think of themselves differently. End users, IS staff and managers and private physicians have all had to align themselves under a different “master.” Some have said that this “psychological” change is the most difficult.

Example: The staff nurse who had worked in this community hospital for 30 years and seen administrations come and go, needed to get a new paycheck distributed from our parent corporation. She needed to adopt medication administration practices and policies that were optimized at a sister academic medical center. Despite union representation, pay practices were aligned with other hospitals in our system. She needed to think of herself as giving the very best care for our community setting, but being supported by fiscal and administrative processes that span the life of the patient.

Example: The private physician adopted a common electronic medical record that is viewable by clinicians across the network who have a need to know. Inputs to this record must conform to policies set for clinical care, quality monitoring and pay for performance contracts. Changes in policy or software need to be vetted by numerous people. The physician needed to think of himself as part of a care continuum with shared services rather than a small business independent of any other encounters. As you can imagine, this transformation remains in process for some.

Example: The IS manager who came to the hospital to run technology needed to collaborate with corporate groups engineering the computer network and running the Help Desk. Tools and processes changed and functions were “outsourced” to the parent company. Of course, this drove job activity changes, but even more, it forced the IS manager to consider whether she wanted to be part of an integrated delivery system providing the necessary information at the point of care. She needed to decide whether she wanted to help optimize, and in some cases lose control over administrative processes that are not the core competency of a community hospital. The alternative, which is becoming less available, was to move on to another independent hospital that doesn’t have to cooperate with other business units.

It’s challenging to have these conversations. In our market, it’s difficult to find healthcare IT talent, so in many cases, we have to wait for this transformation to take place in existing staff. During these times, leaders need to communicate the mission tirelessly and show patience as people consider their identity. We wait and listen to good employees as they make their way. In some cases, a crisis can be created to help people decide where they stand. In our case, we used budget cuts, moving the Help Desk to corporate and service metrics to improve processes.

Expect more of this with the ARRA. What we have been going through is small compared to an entire industry learning to collaborate. The new mandate is to share information rather than use information to differentiate and to compete. The principles are sound – collaborative care to deliver the best quality at the best price. Build an information systems infrastructure that will support those goals. Vendors, providers and payers will all have to make significant changes to bring that about. The change starts with individuals considering their identity and loyalties.