Joseph Conn: Thank you, Pat. Good morning, everyone, and, again, I’d like to extend my welcome to the webcast. We have two excellent practitioners of health information technology for you to listen to and question in the next hour. First up is Dr. Thomas Deas. He is a board member and past president of the North Texas Specialty Physicians IPA. It has about more than 600 physician members and 350 of which are EHR users. The North Texas Specialty Physicians were the winners of our contest this year, and so I know you’re going to enjoy hearing what Dr. Thomas Deas has to say. Doctor.
Thomas Deas Jr.: Thank you, and good morning to all the participants in the webcast, and thank you Mr. Conn and especially to Modern Healthcare for the honor of presenting North Texas Specialty Physicians’ experience in the development of SandlotConnect, our health information exchange. North Texas Specialty Physicians is an independent practice association. It includes both primary-care and specialists physicians in solo and large independent practices. We’re based in Fort Worth, but we provide care over a four-county area in the Fort Worth, Texas, area. Since 1997, our core business has been the management of capitated risk, and we currently manage capitated contracts for over 25,000 Medicare Advantage patients. Fifteen hundred of those patients are in our own Medicare Advantage PPO, which we began in 2008. Our first step to develop an electronic health record, seven to eight years ago, was achieved using claims-based data to create patient profiles. These include diagnoses, patient visits, procedural services, medications and a list of the physicians involved in the patient’s care, but unfortunately these profiles were quite limited by the nature of nonclinical claims data and the 60- to 90-day delay related to getting that claims data into the patient profile. So in 2006 and following this experience, our physician leadership proposed creating a physician-designed health information exchange that would provide us real-time patient information. It would assure faster, better, safer patient care, and help us achieve fiscally responsible care. And in addition, enhance our physician-to-physician communications.
Next slide. So in 2006, NTSP funded the development of SandLot, which remains a wholly owned subsidiary of NTSP. SandLot has provided North Texas Specialty Physicians approximately 100 electronic medical records each year, including licenses and support for three years. In addition, SandLot Connect provides portal access to the health information exchange at no cost to our NTSP physicians who have an EMR or who are without an EMR, still on a paper record. Our community impact so far includes three interoperable electronic medical records, which are NextGen, Allscripts Enterprise and eClinicalWorks. We have seven hospitals connected through Epic, two national laboratories, two radiology groups in the region, and two e-prescribing systems. Of course this list continues to grow as we aggressively encourage all of the healthcare providers in our community to participate in this open health information exchange.
Next slide. I’m a practicing gastroenterologist in full-time practice. In fact, 30 minutes ago I was in my endoscopy unit doing procedures. So I believe that a clinical vignette is clearly the best way to demonstrate the transforming power of SandLot Connect, which provides clinical information right here, right now at the point of service. I saw this patient as I was preparing for the webcast: He’s an 86-year-old gentleman who presented to my office. He was self-referred as he came with no information, and some history, which indicated he had inflammatory bowel disease for a three-year period, had symptoms consistent with intermittent bowel obstruction and anemia. He had actually been admitted in the previous month for what he described as ‘Fluid on my lungs.’ So I’m in the office talking to this gentleman for the first time with essentially no clinical information. By accessing SandLot Connect, the health information exchange, I was provided with multiple diagnoses, including his Crohn’s disease, iron deficiency, anemia, aortic stenosis, atrial fibrillation, [unclear: 7:26] insufficiency as well as diagnosis of peri infusion and pericardial fusions at the prior admission. I had his laboratory results including the CDCs and chemistry and fluid analysis from the thoracentesis, X-rays. His gastroenterologist consult in the hospital and his discharge summary, which included his discharge plan and his discharge medications. I had all the information I needed right at the point of care to make the best and most cost-efficient and timely care decision for my patient. Even the family and the patient were amazed at that. If there are basketball fans out there, this SandLot Connect is the equivalent of a game-winning three-pointer at the buzzer nothing but net. For physicians this is a golden opportunity to improve the care and improve the cost-efficiency of the care we deliver.
Next slide: The clinical information in the electronic health record of over 1.5 million patients is readily available to physicians using both an electronic medical record and paper records. For the EMR user, there is an interoperable exchange of clinical data to and from the electronic medical record. This includes demographics, diagnoses, patients, procedures, allergies, physician providers, laboratory and radiology and hospital summaries. Access to the patient information occurs without leaving the electronic medical record, called a CCR, which is a Continuity of Care Record, is transmitted to the physician’s EMR at the time of the patient’s visit. In addition, when that visit is complete, the electronic medical record transmits an updated Continuity of Care Record back to the health information exchange, and this occurs, essentially, instantly. In addition, of course the physicians have added EMR functionality of use.
Next slide: However, for the physician still using a paper record, the HIE portal allows them to access the same information previously listed as shown on the slide. They also have some EMR-type capabilities through the portal, including the ordering of lab and radiology tests. They can e-prescribe and have the ability to communicate securely with other physician providers. They also have a referral system on the portal for referring patients.
Next slide: Currently, SandLot Connect contains electronic health records for over a million and a half unique patients. We’re adding about 100,000 patients a month. We have over 1,400 healthcare professionals who are trained in using the portal through the website. These include those on EMR and those who are not. We have over 350 physicians that are connected through electronic medical records. There are approximately 50,000 Continuity of Care Record transactions that occur each day.
Next slide: Health information exchange is not without its challenges in development. Mike (Restuccia) and I were talking just before this seminar about some of the challenges that he’s faced as well. We found essentially two that I’d like to mention today: One is creating a financially sustainable model is essential. Each community really must develop an economic model that fits their individual circumstances and needs. For North Texas Specialty Physicians, our return on investment derives largely from the improved quality of care and cost-efficient management of approximately $200 million in annual healthcare costs for our capitated patients. And so the return for our investment is in that efficiency that we achieve. Additionally, and one of the probably biggest issues we face in our community is the proprietary and enterprise interests in a community that may thwart development of a robust and seamless health information exchange that gets around just increasing size of information silos. The most clinically effective HIEs really include information from the entire spectrum of healthcare providers in the community. Efforts by hospital systems, vendors, physicians groups and other proprietary interest just to sustain their own silo information, sometimes it’s more self-serving than patient-serving, and becomes counterproductive. So I would suggest that most communities really need a system by which whatever electronic records they have devised can communicate with others to share that information.
Next slide: Our future in encouraging because No. 1, we continue to grow with increasing adoption like physicians, other providers, hospitals, and we continue to add additional interoperable electronic medical records. By the end of this year, we will have developed quality measures and reporting tools for individual patients and population management and the creation of knowledge-based guidelines and reminders for achieving more consistent chronic-disease management. Both of these tools are based on the rather robust information database contained in the exchange. We are currently on course to achieve all of the meaningful-use requirements as they are at least currently defined, and we feel like, and in our particular IPA and in our setting, that the combination of the HIE SandLot Connect and our history with risk-management infrastructure will also facilitate the development of an effective accountable care organization.
Next slide: If you would like more information, there are a couple of websites listed here which you can access to find out more about NTSP or the SandLot solutions. In addition, there’s a phone number if you’d like to call and inquire or ask questions. It’s certainly available. I would like to thank you all very much for your interest and attention today, and I think I’ll stop there. We do have a couple of screenshots of the HIE portal, and I think I’ll leave that for questions if there are those who are interested in seeing those. And we will close at this time. Thank you very much. Mr. Conn.
Joseph Conn: Thank you, doc. And we will get back to those slides. I think we have a little extra time in your presentation, so we’ll do that. But let me move on and get Mike on the phone here and in the presentation. Our second guest and the second-place winner, representing the second-place winner in our contest is Mike Restuccia. Mike is the vice president and chief information officer for the University of Pennsylvania Health System. And Mike’s project he’s going to be explaining is how they’re extending electronic health records out to their physicians—affiliated physicians—and so, Mike, I’ll turn this over to you.
Mike Restuccia: Thank you very much. First, let me take a moment to thank all the participants and also thank Modern Healthcare and HMS for sponsoring this webinar. In addition, I’d like to congratulate Dr. Deas and his team from North Texas Specialty Physicians on being selected the No. 1 case study. Clearly, they’re doing some great stuff, innovative, challenging and successful, so that’s great stuff, and congratulations to you, Dr. Deas. For point of reference, I’ve been at the University of Pennsylvania Health System for about 3½ years, and my goal today is to share our experience here at Penn with the implementation of our Epic ambulatory electronic medical record and discuss how that solution has served as foundation for many of our patient care, quality, research initiatives, and in particular, how we supported our case study that was submitted here to Modern Healthcare, associated with our chronic care support of diabetes patients. So I’ll work my way into that.
So, I’ll start off and my quick agenda is to talk a little bit about who Penn Medicine is and the University of Pennsylvania Health System. We’ll share some thoughts around our philosophy as an integrated health system, academic medical center, what our philosophy is around IS—rather briefly on that. We’ll talk about some of the lessons learned in our implementation strategy of the Epic EMR, and how we deployed it throughout the health system. Then we’ll talk a little about the diabetes project and then our preparation for meaningful use. So here on the first slide, a little about Penn Medicine. Penn Medicine is really the combination of the University of Pennsylvania Health System, which is our patient-care centers, along with our University of Pennsylvania School of Medicine, which is really our research component. So we have several missions: patient care, research as well as academia, and for this presentation I’ll spend most of my time speaking about the patient-care facility. As you can see, we are three hospitals, over 2,000 physicians, supporting the Philadelphia region and supporting this vast enterprise that’s virtually $4 billion in revenue is our information system.
And I’ll just briefly touch upon two things here: One is from a philosophy perspective, we look to have common systems support common functionality across the enterprise, and what that really means is I have what I call our pillars of strength. So if I break our environment up into four different segments, my ambulatory EMR segment is supported by Epic and Epic only. We don’t have multiple EMRs in the ambulatory setting. On the inpatient side for clinicals, we utilize the Eclipis Sunrise Clinical Manager solution, and, again, each hospital uses just Eclipis, the same version, the same database, etc. From an ambulatory practice management perspective, we’re presently utilizing the IDX Systems. We’ll be migrating to the Epic practice-management system in about nine months. And then from the inpatient-billings perspective, we use the Siemens Invision system. So common systems across the enterprise are a key to our ability to leverage IS at this point and time.
Given the vastness of our enterprise, and the fact that at this point we have multiple vendors in our environment, we strongly promote the concept of access for information and providing our clinicians, physicians, department heads and others ease of access to information. And we do that through a few ways: First and foremost, we’ve developed a homegrown physician portal product that we coined and termed ‘MedView.’ MedView is a read-only system that provides a view-only capability into the many disparate systems that we have throughout our organization, and for point of reference we have somewhere around 40 different clinical solutions that MedView provides a look into. I know that it’s easy to use and I know that it’s highly utilized because our statistics show that we have about 15 million hits per year on that system. So utilization and getting access to information is something we’re able to provide quite well. Secondly, we have rolled out a solution from Sentillion for single sign on and context management. I know there’s multiple vendor solutions out there that provide such a similar solution. We selected Sentillion, and what that does on our clinical workstations of which there’s approximately 4,000 throughout the enterprise, the ability to sign on under one single sign on and password, and within the context of the patient be able to flip from system to system in order to view patient information again is another way that we’re able to provide easy access to patient information. And then finally, we have what’s known as our data warehouse that we’ve coined ‘Penn Data Store.’ And Penn Data Store is approximately a billion four rows of clinical information that’s gathered from the multiple clinical information systems throughout the organization. So access to information and common systems are two of our themes within our IS department.
Next slide: When communicating or trying to communicate at least with my executives here at Penn and explain the directions that we’re going, I try to utilize this particular slide, which is a common slide throughout all of the IT industry. It’s clearly not healthcare-specific, but basically the concept is you’re moving from the far left bottom column or corner in phase one to where you’re aggregating and beginning to accept data. And these translate a lot into our transactional system, whether it’s the ambulatory EMR, whether it’s CPOE, which at this point all three of our hospitals are 100% CPOE for all order, medication orders, etc. As you’re moving up the ladder, you start to get to a point where, boy, I have all this data, now what am I going to do with it and how do I make it meaningful and usable? And that sort of gets into your decision-support-type criteria. Some of our clinical alert and aggregating data in some way to make it more meaningful. And I’ll touch just briefly upon phase three because with a research mission also, it’s important to us that we begin to get to the knowledge phase. And knowledge to us here at Penn is being able to provide personalized care, personalized medicine. That begins to get us into endeavors of genomics, combining the genomic information with the pheno-type type of information captured in our patient-care system. It’s an area that we have strategized around for a period of time and now have organized around. And my hope is, in the future, I’ll have some great things to report back to the group here along that perspective. I know certain groups have made good strides in this area. Many are still exploring and discovering. And we’re clearly in that discovery phase.
Next slide, please. OK, so, with 2,000 physicians to bring up on an ambulatory electronic medical record, we’ve had a bit of a journey. My predecessors were wise enough to know back in the late 1900s that having a common electronic medical record in the ambulatory setting would serve as great glue to tie our community together, and thus a decision was made in 1998 to contract with Epic. That was a great solution and great decision at perhaps the wrong time because soon after that the health system began to experience some very significant financial issues that brought many projects, including the rollout of Epic, to a grinding halt. So, as you can see on this particular slide, the first seven years we really didn’t achieve a significant amount from a deployment perspective of our ambulatory EMR. But, as with all things, the environments change. And what changed here at Penn was the decision to build an 800,000-square-foot ambulatory center here on campus, which is now known as the Perelman Center. A picture of that Perelman Center was at the very beginning on slide one, but what was monumental about that particular decision, at least from an IS perspective, was the building was designed, architected and built without any space for medical records charts. And thus, the point came that if a practice wanted to move into this brand new, spanking new, great facility, the practice would have to come up on the ambulatory electronic medical record. We furthered that theory and said, ‘Not only do you have to come up on it, but you have to come up on the system six months prior to actually moving into the new facility.’ And so that created a great impetus for us to get buy-in and ultimately adoption into the use of the ambulatory electronic medical record. Two things I would say about this slide: One is clearly it’s taken us awhile to get to the point where we now have 1,500 physicians that are up on the electronic medical record. By February of this year, we’ll have approximately 2,000, and thus our initial phase will be complete. But I think also what’s noteworthy is in the last three years we’ve really accelerated the pace based upon the building of the Perelman Center. And not only do we provide the electronic medical records to family medicine- and internal medicine-type physicians, but we span all specialties, all subspecialties. And that to us has been one of the biggest lessons learned as we’ve gone through our deployment that one size implementation really doesn’t fit all practices. Within specialties, one size pretty much does fit all. That’s what our experience has been, but, you know, the way we build the cardiology workflows, which is different than GI, which is different from pulmonary, which is certainly different from surgery and oncology. So developing some flexibility in our implementation approach was truly a lesson learned for us. And I’ll say at times we’ve learned the hard way through some rather heated discussions with our physician community. But I think we’ve come a long way, and the fact that we’re now activating at least 10 practices a month, is evidence of the distance we’ve traveled. I think, also, at the end of the day, and I’ve sat through many presentations where really it’s all about the workflow. I can’t stress enough for the need to work collaboratively with our operational team in order to drive the implementations and ultimate adoption of the systems. Over the years we’ve become great partners with our operational team, partners with IS, and that’s generated a lot of success. And I think the third thing I would just share from our learning is: Initially, we tried to compress an awful lot of education and learning for the physicians in a rather short period of time. We’ve asked them to attend anywhere from eight to 16 hours of classroom training. We provide some shoulder-to-shoulder training. We’ve asked them to learn to navigate the system, and in some instances, we had to teach people how to type on the keyboard. But what we learned is if we showed up anywhere from 12 to 15 months prior to their actual activation date, if we installed the demo system in the privacy of their office or home, gave the physicians the chance to be able to navigate the system, how to point and click appropriately, it went a long, long way in reducing the stress and improving the activation experience. I would also note that we have approximately 400 of our physicians that use speech recognition, which is yet another education piece that has to take place. And when we could spread out that learning and actually let them start utilizing the speech-recognition system months before the activation, it just made the whole go-live experience so much better.
Next slide, please. So, I think we’ve recognized many benefits with the deployment of our electronic medical record in the ambulatory setting. As mentioned, it really has served to be the glue that ties our physician community together now, and with as many specialties and subspecialties that are offered here at Penn, many of the physicians have commented on the continuum of care and the continuity of care that can be provided and the appropriateness of care that can be provided as they see the patients that go through the Penn system. We’ve begun to leverage some of the decision-support capabilities, and I’m going to chat about that in just a second, with our diabetes chronic-care program. Based upon the use of not only some of the tools in the EMR, but also the use of the speech-recognition system, we have dramatically reduced our transcription costs in many of our departments. And that’s an area where we continue to find even more and more benefits, so that always makes our finance people pretty happy. The major insurer in our region is Independence Blue Cross. Based upon our deployment of the EMR, we’ve been able to work with—tighter, closer with the insurer to develop some pay-for-performance programs that have been beneficial to the health system and obviously our patients. And, with the deployment of the patient portal, we have about 20,000 patients now utilizing our patient portal, there seems to be improved physician patient satisfaction in two ways. One is they’re much more engaged with their physicians in their care treatment. Our patients are able to see lab results. They’re able to communicate with their physicians via e-mail, secure e-mail. In addition, the feedback received is when they see their physician using the computer and being able to access information from prior visits, whether it was with this particular physician or with another specialty, it does give our patients more satisfaction and more comfort that indeed they’re being provided the right level of care and the right, appropriate care.
Next slide. So let me just touch upon, for those that have not seen the case studies that we submitted, basically it was one of our physicians, through some work she was doing with the governor’s office, has went ahead and created a project for her patients that were predominately diabetes-oriented. And she was trying to improve the overall compliance on certain key measures of her patient population. And through some education with the governor’s office and then through leveraging the EMR, the results she achieved across multiple areas, such as better management of blood pressure, lowering of cholesterol, compliance with foot and eye exams, were really pretty astronomical in just the nine-months time period. So I’ll just briefly share this. The three things she really did in leveraging our EMR to achieve those superlative results were first she was able to go into the EMR database and do a query and identify a patient population of that she could then put into a separate database, a registry, and begin to track. So patient identification was the first key where we leveraged the EMR. The second thing she was able to do was work with her colleagues and develop specific treatment plans, protocols, report cards, action plans that could be provided to the physician at the point of care as part of their normal workflow in order to ensure and perhaps guide their behavior when seeing their patient population. Dr. Deas’ point in this project was she didn’t want to introduce anything special or additional for her physician community. It was she wanted to be part of a normal workflow, and so at the point of care, through our normal screens with little pop-up windows, was a very effective way of suggestion behavioral change not only for the physicians but, again, for the patients. And then finally Dr. Day and her team were able to leverage the patient portal to keep the patient aligned and engaged in their treatment, receiving reminders that it might be time to come in for your foot exam or whatever it might be. And sort of prompting the patient to respond and get more engaged. Those three things of leveraging the EMR certainly you could have achieved such results, and I did ask this question through the project, but it would have taken far more resources, far more time and clearly would not have been as efficient.
What I’m going to close with, and we’ll flip to the next slide. In the interest of time, I’ll close on this slide. I think we achieved here at Penn, many, many benefits from a patient-care perspective, from an operational-efficiency perspective, from a patient-satisfaction perspective through the EMR. One of the things we didn’t anticipate was through our efforts, our preparedness for meaningful use. And much like the folks from North Texas, we feel pretty confident that, at least for stage one, we’re in a pretty good position to meet the guidelines and the regs associated with meaningful use. We have a report card that we have developed here, and I laid it out for everyone in full disclosure to show where we think we’re feeling good, and those are the boxes that are in green, and those that we have a little bit of work to do. Interestingly, the areas where we have some work to do, the functionality exists in the system. For whatever reason, we’ve made the decision not to activate that particular functionality, or in the form of report quality measures at the very bottom, we just haven’t gotten around to addressing that. But we certainly feel good that the implementation of the EMR, that decision that was made years and years ago, long before meaningful use became the concept that it is today, that we’re fairly well-prepared for addressing that meaningful use, and certainly the benefits for a place like Penn with 2,000-plus doctors are pretty substantial. So with that I’d like to close, like to thank all the participants, and, Joe, give it back to you for questions.
Joseph Conn: Mike, thanks a lot. I appreciate it. It was interesting, and I saw the acceleration in adoption, and I think a lot of folks out there that are looking ahead down the road to try and get to that point are heartened by this fact that after spending a long time setting the table, you can ramp it up as quickly as you have. I imagine the folks in the government would be really happy to see that slide, too. But, yes, so folks out there listening, we can open the floor for questions right now. I have a few already, but please ask your questions online. Let us know, and we’ll try and field as many as we can to our two panelists. The first question today I want to direct to Dr. Deas. The question is: Do you require your physicians to use e-prescribing tools that’s available to them? I know that you have it two ways. You can have it through the doctors that do have EMRs, typically they’re equipped with e-prescribing, but those physicians who you’re providing the service, software as a service over the Web can access that e-prescribing tool online even if they don’t have an EMR, but do you require it? And if so—if not—what percentage of your IP members that are accessing the system are using e-prescribing?
Thomas Deas Jr.: Thank you, Joe. We do have two options for e-prescribing. One is in the electronic medical record in the office for those physicians who are on it, and the other on the portal if you are on a paper record. Because we’re an independent practice association, we are essentially a conglomeration of small and large practices for which we don’t have the authority to require. It’s not like a fully integrated health system that has employed physicians. If you want to continue your employment, this is the way we’re going to do it. All of our physicians are essentially in their own practice, so no, we do not require it. We certainly have encouraged the adoption, and that has seen some rapid growth. And we also provide economic incentives to our physicians. Because we manage risk, we can establish our own performance measures. So we have established incentives to the physicians for using the portal, implementing EMRs, using e-prescribing. Those are the types of measures to become quality measures and performance measures for payment. And that has helped to some degree.
Joseph Conn: Thank you, doctor. The next question will be directed at Mike. You have established a very profound enterprise strategy toward development or growing out your systems. You have the Eclipsys inpatient, Epic outpatient, you mentioned that you need to—one size doesn’t fit all. My question is is there’s the whole best of breed vs. the enterprise thought and this sort of thing. Do you think that the kind of adaption of these systems to various medical specialties can be done outside of some place where you don’t have the Penn level of IT resources available to that sort of configuration?
Mike Restuccia: So, I’ve been pretty fortunate to work in a place like Penn, large academic medical center as well as several smaller community facilities, and I think the answer to your question, Joe, is absolutely yes. Regardless of the size of the organization, the achievement of the deployment of these types of systems is well within hand. I think within the vendor community, generally speaking, the vendors develop and deliver a product that works—whether it’s an ambulatory EMR, whether it’s a patient billing system. In the year 2010, generally the software delivered works, which is much different than it was 20 years ago—25 years ago when I started in the system. So the challenges are much more around the nontechnical arena, such as governance, such as what Dr. Deas had mentioned about the removal of proprietary interests in systems, allocating the appropriate amount of physician time to learn a system and adopt and get to use the system. So that is one of the big things we found here is it’s really not the technology that is the driving success factor. It’s all the things that go around the technology. We have, and I didn’t go through any slides, but pretty very disciplined governance structure that’s in place. We have significant executive support for the investments we make in IS and the way we deploy systems. Other things that really have driven the success here in addition to the technology.
Joseph Conn: Thanks, Mike. Dr. Deas, this question is directed to you. Mike had a slide there where he did a sort of report card where he thinks he’s going to get at meaningful use stage on some of the choice menu items that are colored in red. I wanted to ask you. Since you don’t have a level of control that Mike enjoys with yours. How do you guys help your IT members reach meaningful use, and what do you think might be your biggest stage one challenges?
Thomas Deas Jr.: Very good question. First of all, let me echo what Mike has said about it’s everything that wraps around the technology that makes this work. If we’ve learned nothing else from our project it is that the IT solutions, those guys do a real good job of creating the product. But it becomes a very expensive paperweight on a doctor’s desk if you can’t get him to use it, so that is a major emphasis. For us, what our goal is as an IPA is to provide that infrastructure and the ability to meet meaningful use. We can’t leverage all the physicians to do it, but we want to provide the health information exchange, the available EMRs, the connectivity of the quality reporting, the patient portal. We will provide that infrastructure as an IPA for those physicians who do want to meet meaningful-use requirements. And that may be 20% of the IPA. It may be 50%. And over time, of course the numbers will grow. But we’re not going to be able to as an entity say all 600-plus physicians are meeting meaningful use. But we will have the tools available for them to do that if they choose to.
Joseph Conn: Thanks, doc. Mike, I’m going to go back to you on a question regarding integration. I have a couple questions, and I think both of them are somewhat related. One of them is: Are you doing integration between Epic and Eclipsys. And the other one: Are you using a commercial product, such as Amalga or others, to develop your data warehouse.
Mike Restuccia: I’m just writing those down. So, we’re doing some minimal integration between our inpatient Eclipsys system and the Epic system. The discharge summaries that come out of the inpatient setting, we’re able to interface them into the Epic System so that they’re readily available in that way. But generally speaking, we are not doing a lot of full-fledged integration amongst the two systems. We try to leverage our MedView product to aggregate information and a good example would be medication. So we have a separate emergency department system, we have a separate clinical system, we have a separate EMR. All capture medication. Through the MedView system, we’re able to present on one single screen the meds, the problem lists and other pertinent information in those three settings that a patient may have been on. But true integration, we can’t take credit for that. And from a data warehouse perspective, I think that was the second question, we are not using a commercialized product. We are homegrown to develop that data warehouse solution on an Oracle platform.
Joseph Conn: Thank you, Mike. Dr. Deas, another question: How do you ensure the patient information that’s shared is accurate? For example, patient demographics or insurance cards. And do you have someone checking this information and editing it?
Thomas Deas Jr.: Again, a lot of that is variable in the different offices, but from our system perspective, from the information exchange, we use the technical infrastructure for that is Initiate, which does the patient identification across—again, this not being a technical person I won’t delve into that too much—there’s a very high reliability that the patient who is Joseph Conn with a date of birth will match up within the data system. And there’s not a crossover. If there’s any question of patient identity, then that’s worked manually by an individual to assure that the information gets in the right place. You know, our physicians have asked the same question, ‘How do I know everything in there is correct?’ Well, you don’t. In fact, when we used to live on paper records, we didn’t know it was correct either. In fact, I would get frequently paper documents, charts and records and diagnoses and medicines that were wrong. So it’s really up to the physician to take make information available, which they should really be deeply grateful for and review that with the patient, and say, ‘Are you on this medicine? Did you take this medicine? Are you still taking it or is this diagnosis fresh?’ You still have to take a history and talk to the patient and sort of blend in their history with the information. But I would argue that in one case where a patient came in to see me and was scheduled for a procedure and just didn’t remember the warfarin they were taking; it’s a blood thinner that showed up on the health information exchange. That information can be dramatically beneficial at the time of care. But you do have to cautious and be aware that not everything in there may be absolutely correct.
Joseph Conn: I forgot two somewhat related questions, Mike. One of them had to do with the building itself, and I’ll be interested in this because I actually did some reporting on this early in my career about moving docs into a building, who did you have to convince most to build a building without a paper medical record department, and on the other hand, who was willing to make that leap of faith?
Mike Restuccia: [Restuccia and Conn spoke over each other] … but the folklore as it’s come down in time is the building is an architectural wonder. And in order to maximize the patient-care space and the amount of physicians that we wanted to move into the building required some sacrifices. And one of the sacrifices that was given was no space for medical records storage. And then through our executive governance committees was where we had this electronic medical-records system, could that supplant that space? And all agreed—and this was important from an executive-support perspective—all agreed, all department chairs, all leadership agreed that the Epic electronic medical-records system would be the paper chart, would supplant the paper chart, as practices moved into that building. Strategically, it was important to move into one centralized location. I think many large health systems and academic medical centers have followed that particular strategy. But it was the leap of faith more of the leadership vs. the physicians on the line that made that decision and had that leap of faith.
Joseph Conn: Question back to Dr. Deas: Does your IT system help you to insulate yourself from anti-trust concerns? Are your physicians clinically integrated enough to join to negotiate with payers? Is that on your horizon or are you doing that?
Thomas Deas Jr.: We are not currently. Again, as an IPA structure, there are certainly some limitations on what we can do for an individual practice in negotiating contracts. Now with risk contracts that doesn’t apply because you’re sharing a financial risk. But we have considered the fact that this process of connecting the physicians with better communication, better source and information to the electronic systems does in fact clinically integrate the physicians who choose to participate. And, in fact, as effectively as some fully integrated systems. We have not yet contracted on their behalf, but that’s certainly a possibility that you may well know that the FTC has approved a number of proposals from IPA groups that are electronically integrated. And it just depends on the degree and the quantity of integration there by their judgment.
Joseph Conn: Mike, the next questions for you. There are obvious improvements that were necessary for information systems to software and hardware. What others areas had to be improved and renovated in the physical plant facilities. And what challenges and problems can you share?
Mike Restuccia: So, I think since it was initially rolled out, we had a three-phase strategy in the rollout of our EMR. First, as mentioned, it was all those physicians that were moving into the Perelman Center. They became phase one. Phase two were all those physician practices that had part of their practice in the Perelman Center and had yet to move into the Perelman Center, so that was phase two. And then we have a small group of practices that had no plans to move into the Perelman Center because they represent some of our suburban facilities or they’re pretty distant. And so I think the challenges were several particularly in the older facilities just having space to put the computer required some flexibility. And some instances we have desktops on desks; we have the wall-to-roof solution where we have a pull-down from the wall, so there’s a variety of different options we had to provide in order to fit the existing physical space that was in place. In certain instances, there were some technical things. In the basement of our Perelman Center is a proton therapy center, which is one of only a few in the entire country. And that has just some logistical limitations with literally 8-foot walls surrounding a centrifuge that—so if you’re on either side of that particular facility, wireless connectivity, at times, can be an issue. And certain things had to be put in place to get around that. But, I think generally speaking, the [55:28 ?sitout/layout?] of the rooms created the biggest challenges, and then, tied to that, where are you going to print? Are you going to print in every room? Are you going to print in a central location? How big a printer are you going to need? If it’s a central location, how far are physicians willing to walk from their existing office to get the paper off the centralized printer? Those were some challenges we encountered also.
Joseph Conn: Well, we’re almost out of time. We have enough time for two more questions. And what I’d like to do is to allow since you both have fielded them, I’d like to ask you to ask each other a question. So, Dr. Deas, do you have a question for Mike?
Thomas Deas Jr.: Yes. Certainly do. I’ve been impressed by his discussion and how much of what we did we’re very parallel and the technology piece maybe being the easier part and the adoption piece being the greater challenge. Of course, I think getting the physicians and the healthcare providers to use these systems is critical. We had a lot of trouble with a single EMR didn’t seem to satisfy enough physicians, so we ended up with several EMRs that work interoperably. You’ve done it with essentially one system and made some adoptions. I really like the idea of building a building that can allow no paper records. That’s the ultimate leverage. But what else did you do to try to move the physicians along?
Mike Restuccia: I think like most groups, we tried to make sure we listened, we understood their workflow. We worked hand-in-hand with them, but perhaps the most surprising thing to me in my 3½ years here and particularly on this project, was the point that I felt we actually achieved the tipping point and we achieved adoption here at Penn of the system because, like many, the first few installs, they weren’t going particularly well. And they weren’t going well because we were immature at our ability to install, and we didn’t have all the templates down. You know, our team was still learning. But there came a point that the tipping point occurred, and in looking back, the primary reason, I think that tipping point took place really didn’t have much to do with how good or bad my team was, it really had to do with physician competition and how they viewed one another and how they always wanted to one up each other. I don’t know if that exists at other places, but there’s a bit of that flavor here at Penn, and when one physician who swore to me in his South Philly accent, you know here we are in South Philly, telling me that ‘I will never see the day that that EMR will be in his office.’ And 12 months later he’s back on the phone or at my door saying, ‘I really need to get on that system. How do I move up on the queue?’ The reasoning was twofold. One was some of his colleagues that he either thought less of or whatever were up and using the system successfully. And the second was the referral patterns had begun to change here at Penn, where referrals were taking place from one Epic physician to another Epic physician. And thus, if you were not on Epic, you were starting to get squeezed out of the referral. And that was really an eye-opener for me, so adoption was clearly driven by some of the successes of our team, but it was really driven by physician competition.
Thomas Deas Jr.: I will take that to heart.
Joseph Conn: Mike, we’ve got about one minute left. So, have a quick question for Dr. Deas?
Mike Restuccia: I do. I’m always so impressed particularly within the community setting where I had worked previously on achievements within information systems and pulling folks together. And I was wondering if Dr. Deas could share some of the logistical challenges in trying to govern and communicate and pull together this disparate group of physicians who are located all throughout the Fort Worth area in order to make decisions to govern the group?
Thomas Deas Jr.: It is a challenge because we don’t have the governance or leverage over them, but it is a physician-led organization. Our board consists of physicians who served for a number of years, so we have specialty divisions and primary-care divisions with their leadership. And so we have a very nice governance structure, and, I think, as well a very good way of communicating to our physicians: What’s going on? Why it’s happening. What are the advantages, what are the disadvantages? Over the 15 years of existence, we’ve developed a lot of confidence among our physicians and other initiatives and other things we’ve done. So I think that’s been the key that has helped us to gain traction with those independent physicians and get them to consider implementation of the IT solutions. And I’ll tell you, it has a lot to do with the referral base and where those patients are going to end up as well. So, it’s a good experience.
Joseph Conn: Well, gentlemen, my thanks to both of you. You’ve been listening to Dr. Thomas Deas of the North Texas Specialty Physicians IPA and to Mike Restuccia with the University of Pennsylvania Health System. To my audience, thank you very much and that will conclude our webcast. We’ll have some closing remarks in just a second with Pat Shrader.
Pat Shrader: Thank you. This concludes today’s presentation from two winners in Modern Healthcare’s second annual IT Case Study Contest. We thank our panelists for participating, and thanks to all for joining us today. For those who want to listen to this webcast again, all attendees will receive a follow-up e-mail with a link to the recording of this event available on ModernHealthcare.com/webinar. Thank you for joining us.
Narrator: Today’s presentation was brought to you by Healthcare Management Systems Inc. To learn more about HMS, visit www.hmstn.com or call 800-383-3317. This concludes today’s presentation. Thank you.