One-on-One With Somerset Medical Center CIO & Director of Strategic Planning Dave Dyer, Part II

Somerset Medical Center is a nationally accredited, 355-bed regional medical center, providing a variety of comprehensive emergency, medical/surgical and rehabilitative services to Central New Jersey residents. The organization’s 650-member medical and dental staff represents all major medical and surgical specialties. To learn more about the novel governance structure at the hospital, HCI Editor-in-Chief Anthony Guerra recently spoke with CIO & Director of Strategic Planning Dave Dyer.

(Part I)

GUERRA: I read that you’ve embarked on a $10 million initiative to upgrade the clinical computer systems. Can you tell me about your software environment?

DYER: On the financial side, we’re Lawson for general financials and materials management. Following that, we selected Cerner and put in all the Cerner applications including scheduling, registration, EMR. We have about 20 different applications now, so all clinicals are running on Cerner. We did a big-bang rapid implementation approach back in 2002 where we came up with 14 of those applications at that time, and then we’ve been adding on to that since. And then on the billing side, we retained our McKesson billing system, and we’ve been wrapping around contract management and physician support through McKesson as well. Those are the three main vendors we have.

GUERRA: Some people spend the money and go full-boat Epic. Was that not in the financial cards for you or is that just not an attractive solution for other reasons?

DYER: When we were doing the evaluation – I got here in June of 2000 – we were woefully inadequate in our IT infrastructure. We really needed to rebuild everything from the ground up, from the network on up, and most of the applications that we had were installed in the mid-’80s. So we really needed to do a lot of heavy lifting here.

When we were doing the evaluation process, we looked at everybody, we looked at McKesson, Eclipsys, Epic, and, at that time, Epic and Eclipsys did not have a pharmacy package. In my opinion, and our organization’s opinion, you need to have an electronic medical record and order entry for pharmacy all in an integrated platform. If you want to be successful doing CPOE and eMAR or nursing documentation, all of that has to be integrated. At that time, neither of those products had an integrated pharmacy solution that was live and available (or not in beta testing) at that point in time. That’s why they fell off the list when we’re initially looking.

GUERRA: How many physicians do you have that are employees?

DYER: The majority of our physicians are very independent practitioners. We have about five hospitals that are in a 20-mile radius of us, and most of them have admitting privileges in multiple hospitals. We do have a family practice residency program and we have six faculty there and 21 residents that are employed, one practice that’s an employed physician, and then we have a sleep lab in which we employ the physicians. Outside of that, we have an outside hospitalist group that we contract with to do work for us and we contract for cardiology EKG reads and then traditional radiology and ED services, but everybody else is an independent practitioner.

GUERRA: Any idea of how many independents refer into the hospital?

DYER: We have 700 on our medical staff, of which about 400 or so are active admitters (10 or more admissions a year).

GUERRA: Sounds like a sticky CPOE situation, is it not?

DYER: It certainly is.

GUERRA: Tell me about your CPOE strategy and what you’re doing around Stark.

DYER: Well, let me start with the CPOE piece of it. We came up with Cerner in 2002 and then we launched the CPOE initiative as a phase two of our two-phase contract with them. And so we came up with CPOE in January of 2004 on a pilot site, and then we were planning to roll it out unit by unit.

Our strategy was to provide enough content within the electronic medical record that the physician would see the benefit. So we installed PACS, and we installed EKGs, we interfaced vascular lab reports and lots of other reports into the system and kept building on the content, hoping to entice the doctors to do orders.

We had some very strong positive people within our medical executives committee back then who helped get it off the ground, and then over the last three years or so, we’ve been slowly rolling it out. We fought back and forth to the board level and the med exec level about having it as a mandate, and our medical executive committee has not accepted being told what to do. So we’re at the 65 percent mark right now with CPOE. So 65 percent of our medication orders are put in via CPOE and 35 percent are either telephone orders or written orders, and of that 35 percent about half of those are telephone orders for admitting.

We also provide remote access to our electronic medical record to every physician, hoping that would entice them to do orders from their offices. And then with the gain sharing program that we launched this year, if they want to collect money from the program, they have to make progress on their journey towards CPOE.

There’s a few hospitals around us that are starting CPOE as well so the circle is shrinking, and they know they’re going to have to do it at some point in time.

GUERRA: So HITECH has helped organizations get CPOE buy-in because the doctors will run out of places to hide.

DYER: Yes. The physicians that really get it, they see that care gets delivered more quickly to their patients. They’re not waiting hours for results. The ones that really get it understand it speeds the process of care for their patients. But you still get the ones that will view it as secretarial work, who think it’s not their job to do.

GUERRA: What do you do with them if they’re big earners?

DYER: We continue to try and entice them to do it and show the benefits. I talk with the doctor who is essentially our CMIO about it, and it’s basically one doctor, one order at a time here.

GUERRA: The meaningful use matrix is only requiring 10 percent of your orders go in by CPOE in 2011, so you really don’t have to force your top earners to do it yet. Does that make sense?

DYER: Absolutely. But I’ve been warning them that if they want to participate in gain sharing and HITECH, at some point they have to jump on the bandwagon and get going with this whole thing. So we’re looking at strategies to close that 35 percent gap, and I think we’ll be successful, but you’re absolutely right. There’s no reason to lose business at this point in time, at least for 2011, because not all their institutions are going to be forcing them to do it too. So once they start doing it and see the circle is closing in on them, see that they’re going to have to do it everywhere, they’ll jump on board.

GUERRA: Let’s talk more about your Stark strategy.

DYER: Let me start by telling you a little bit of the history on this. After we got our record up and running, CPOE up and running, one of our physician offices purchased the Cerner PowerWorks practice management EMR system for the ambulatory setting. And at the time, Cerner had developed what they call their Healthe Hub, which is kind of an interface engine, but it’s actually more of an HIE integration tool between classical medical records and physician practices. The group who was very pro-CPOE and very pro-technology suggested that we purchase it and get it up and running. So we’ve established interoperability between the hospital’s medical records and that one practice’s medical record.

Following that, we started and completed a strategic planning process back in November and, like many others, physician alignment was a key component to that overall plan. There’s a couple of things we’re looking at in terms of either employing or working with our primary care docs and assisting the medical staff in any way we can legally. And our COO, who is also in charge of physician recruitment and retention, interviewed a lot of them. They often said, “Boy, we could sure use some help on doing this electronic medical record thing.” This is before ARRA and HITECH.

So we put up a survey in the January/February timeframe of this year asking about interest in electronic health records and if they’d be interested in putting them in their offices. Approximately of the 400 docs that are admitters, there’s been 120 offices or so (which is about 18 percent to 20 percent of them) that already have electronic medical records and other ones were either looking at it or not looking at it, but we had about 30 practices that came back and said they would be interested in doing this.

So working with our executive team, I put together a process and figured out how much money it might take for us to assist the docs, and we came back with a bunch of different models. We landed on a final model which said we would fund 85 percent of the EMR implementation up to a maximum of $10,000 per doc in the office to implement what is preferred, the Cerner PowerWorks piece, because we have the interoperability, but it’s not a program that only applies to that particular provider.

All we’re doing for this program is writing checks on behalf of the practices. So we are not going out and buying bulk licenses and then selling them. We are, on their behalf, after they pay their 15 percent of the fees, we are paying the other components of that to the vendor up to a maximum of $10,000. Now, if they have a non-Cerner EMR that they want to connect to the hospital, we’re also funding a portion of that interface to the Healthe Hub.

GUERRA: Are you happy with that strategy so far?

DYER: Going forward, the biggest piece of this was working with our legal council to get the electronic health record donation agreement straight, and then the health information exchange agreements completed. That process took a good three to four months to get finished. And now, we’ve got two physician offices that have signed up on this and we have six others that are considering it. So they’re very happy, and they were pleasantly surprised by the hospital’s willingness and ability to do this.

GUERRA: Are there a few large IPAs in your area?

DYER: Yes, in Central Jersey. They’re big IPAs but they’re not closely aligned enough to go in and force the docs to do anything. I mean, most of them are looking to get into the IPAs as a master contracting entity, at least in our state, to try and acquire better rates from the managed care companies.

In our region, we’re the first to come out of the box of our five competitive hospitals with this kind of a process. But our strategy is much more focused on the county of Somerville and our primary and secondary service areas. So we’re really focusing on the medical staff here at Somerset, and also there’s a limit to the amount of dollars that we can supply to fund this.

GUERRA: But there’s a clear ROI on those dollars because once you’re integrated there’s a really good chance they’re going to refer patients.

DYER: Correct, you would hope that your outpatient business increases.

GUERRA: Being first to market is very important in this process.

DYER: Right, exactly. Now, we do have a competitive hospital that has a closed medical staff employment model and they are providing records to their practices and to their employed physicians there, so that’s a little bit different. But in terms of independent hospitals and independent staffs, we’re the only one in the area doing this.