Electronic Records for Non-Owned Doctors

In my previous post The top 10 things that will keep me up at night in 2008, the number one project is providing electronic health records (EHR) to non-owned physicians.

This will be the first of a series of posts about this very complex project. My posts will detail the cost challenges, the partnership we've built to execute the project, and the technical approach we've taken. Since this is truly a work in process, I'll publish these posts each week over the next few months.

Since 2002, my IT teams have provided electronic health records to every owned/closely affiliated clinician of Beth Israel Deaconess, using our home built webOMR software. We even have a Medical Executive Committee policy mandating the use of electronic health records for owned clinicians by July 30, 2008. 'Use' is carefully defined, since we want all our clinicians to update the problem list, create an electronic note for each encounter, and perform all medication management (e-Prescribing, medication reconciliation, allergy documentation) electronically. Of interest, recent data collected by David Blumenthal of Massachusetts General Hospital concludes that only 4% of clinicians in the US have this level of use of fully functional electronic health records.

Since Stark safe harbors now enable hospitals to fund up to 85% of the non-hardware implementation costs of private practice electronic health records, my teams are now expected to provide EHR solutions for all the non-owned affiliated BIDMC affiliated physicians in Eastern Massachusetts. This is a very different project than providing applications and infrastructure to owned clinicians, which we manage, on a network, which we manage.

The planning for the project includes the following major issues:

1. Designing Governance – My typical steering committees are drawn from hospital senior management, employed clinicians and hospital staff. The governance of a community-wide electronic health record system must include members of the physicians' organization, private physicians, community hospital executives, and legal experts.

2. Modeling costs – The 'hydraulics' of the project budget are quite complex. The hospital wants to support implementation for as many physicians as possible but has limited capital. The physicians want as much implementation subsidy as possible since by Stark regulation they have to fund all hardware and ongoing support themselves. The number of doctors implemented, the level of subsidy and total costs for all stakeholders are interrelated but each party has different goals.

3. Planning for distributed users – These non-owned clinicians are widely dispersed throughout Massachusetts and New England in urban and rural settings. Bandwidth varies from 20 Megabit Verizon FiOS connections to 56K dialup. Technology sophistication varies from fully 'wired' clinicians to offices run on 3x5 index cards.

4. Managing the project – CIOs traditionally serve hospital-based customers. They may not have the bandwidth or expertise to serve non-owned geographically dispersed customers.

5. Building a scalable infrastructure - The architecture must be designed to minimize costs, maximize reliability and support a project scope that is continually evolving.

6. Deploying staff - The existing hospital IT staff is not optimized for supporting networks, telecom, desktop and application at hundreds of remote locations. The physicians' organization and clinician offices do not have the staff or expertise to execute this project.

7. Creating the Model Office – A clinically integrated network of providers in a community will want to adopt a standard EHR configuration with common dictionaries to support healthcare information exchange and continuity of care. Standardizing software configuration means standardizing workflow, which requires business process re-engineering. Practice consulting is needed to balance standardization with specialty specific processes, ensuring that providers buy into the new workflow and staff are appropriately trained.

8. Obtaining all the funding - Once the scope, architecture, staffing and cost modeling is completed, the funding must be obtained from all of the stakeholders. State and Federal governments are not likely to contributing anything. Payers may fund the outcomes of EHR use via pay for performance, but are unlikely to pay for implementation.

9. Specifying the order of implementation - How do we choose the most appropriate offices for pilots and once those pilots are completed, how do we place hundreds of clinicians in a well ordered queue for rollout?

10. Supporting the practices – Hospital support models depend upon standardized networks and desktops with end to end control over the quality of service. Supporting heterogeneous practices requires on site, high touch, higher cost service.

My goal is to create a blog entry for each of these issues. Next week, I'll publish the governance model. The following week, I'll post the detailed considerations we're using to develop the cost model (the finished models will be published under 'obtaining all the funding', since they are still evolving). By the time all 10 posts are done, we'll be live in pilots with 4 practices and I hope to be able to sleep again.