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12/17/2013
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Partners HealthCare CIO: Inside Our Clinical Transformation

CIO James Noga says the largest healthcare system in Massachusetts is proud of its technological leadership, but still needs to do better.

Because the transition to Epic will take time, Partners continues to refine its homegrown ambulatory care EMR, which in recent years has been updated to compete with what today are more commonly called electronic health records (EHR) systems, reflecting an expanded vision of how these systems should operate and interoperate. In the near-term, Partners' efforts at keeping up with federal Meaningful Use standards for electronic records are based on certification of that homegrown system.

I asked about the concerns I shared about these systems in a column on Why Doctors Hate EHR Software, but Noga thinks Partners doctors are past that point.

"The first six months can be very burdensome on a doctor, before they start seeing the benefit," Noga says, but once physicians have made the transition "the majority will tell you they provide better patient care through use of the record." It helps to provide niceties like mobile access to records, allowing doctors to look up patient records from wherever they may be. That's something Partners already offers for its custom ambulatory records system -- and those are usually the records doctors most need mobile access to -- but the Epic version will be an improvement, offering a more complete record of hospital and outpatient visits, he said.

Where there is dissatisfaction, it's likely as a result of hospitals and practices chasing Meaningful Use incentives in a way that led them to move too quickly, with too little planning, Noga says. "Most really good implementations plan for a drop in productivity first 6 months," he says, meaning they make accommodations for the likelihood that a doctor learning to work a different way might wind up seeing fewer patients in a day.

"Once they've run the gantlet and gone through a stabilization period, no one would say 'I'm going to give back the electronic health record,' " he says.

Standardizing, while still innovating
Part of the transition Partners is going through is striking a new balance between innovation and standardization. It created its own healthcare IT systems at a time when there were none available that met its requirements. Now, it finds itself paying a price for having non-standard systems. At the same time, investment required for keeping custom EHR systems current no longer makes sense, he says.

"At some point, we realized we're supporting these transactional systems that are available in the market today," he says. "What we want to focus our energy on is: what aren't the healthcare IT vendors doing?" Epic was chosen as a system his staff felt would provide the right base functionality, while still providing web services interfaces and other means of innovating beyond that base.

"They also use Cache as the underlying database, which is what we've used here -- of course, the origins of Cache go back to Mass General and MUMPS," he added. That is, the data management and middleware product marketed as InterSystems Cache is derived from what was originally known as the Massachusetts General Hospital Utility Multi-Programming System when it was created in the late 1960s for managing hospital data. Although it's not a standard relational database management system, that's just fine with Noga because Cache is "a very scalable database that can do transforms into relational" when necessary, responding to queries in the RSDBMS Structured Query Language.

"I always smile when people say Cache is an antiquated database -- if you look into the history SQL and others are equally as antiquated," Noga said. "To me, it's how you use them -- and what you use them for."

Having confidence in the ability to extend Epic was important because the research institutions that are part of Partners are often ahead of the curve in the ways they use new kinds of healthcare data. "In areas like genetics and genomics, we're doing some leading edge work, so maybe there we'll build alongside Epic -- and maybe someday Epic catches up," he says.

Partners plans to take advantage of Epic's MyChart patient portal, but will probably embed components of that software in its own website rather than accepting the Epic personal health record system wholesale, Noga says. Partners already offers a patient portal that's fairly successful -- close to 700,000 patients who've signed up and actively use it -- and "we think there will be things in addition to Epic functionality we'll want to provide," he says.

Overall, he was impressed by the catalog of extensible web services Epic provides, which is more extensive than what Partners was able to create internally.

Meanwhile, one of his concerns is IT's role in "allowing innovation to continue to thrive." Given the research mission of the university hospitals in the Partners system, much of that innovation originates outside of IT, but IT still has a role to play in supporting it. For example, he is working on refining Partners strategy for making use of big data technologies.

"There's a lot of opportunity there, when you look at phenotyping, genetics, image data, and biologic data repositories -- all of that is going to significantly advance our ability to advance medicine through research," Noga says. "Within the organization, we do have a cadre of what I call true data scientists -- but we'll have to grow that even more. It's true that the analytics you do for operational purposes or financial analysis is different than the data science you need to mine data from big data approaches." Fortunately, Partners has the opportunity to tap local resources like MIT for help in some cases, he says.

The centralization of patient data stemming from the Epic implementation should also have some benefits for research, Noga says. "In other words, how do we notify a primary care physician that they have a patient eligible for clinical trial? Epic will allow us to do that much more easily than we can today."

Accountable care
At an even more fundamental level, Partners needs to make better use of data to manage patient health -- not just out of altruism but because reimbursement will be increasingly based on demonstrated success at keeping entire populations of patients more health, on average. That means organizations like Partners are going to be taking on more risk, and the best way to understand and minimize that risk is with better data.

"This goes back to why we're going to Partners eCare and clinical transformation," Noga says. "Being a pioneer ACO has really allowed us to be a learning organization," Noga says, as has participation in CMS demonstration projects. "That's helping us architect what Partners eCare will be in the end."

For example, just by implementing a system for alerting primary physicians when a patient shows up at the emergency room, Partners found that it was often able to avoid the need for the patient to be admitted to the hospital and also deliver a better outcome for the patient. Similar alerts and notifications could pay off in many other areas, and Partners is working to expand the system. Still, so far, but only "a sliver of the patients" are notifications and only a fraction of the potential is being met, he says.

What's important to understand is that you never achieve the perfect system in one step, Noga says. "You bring up a system, you stabilize it, and then you learn, and then you have to optimize it. The mistake I've seen is people make is they think when you cross the finish line, the race is won. In fact, the race has only begun. That's when you have a baseline system in place, then you really need to focus on analytics and asking, am I seeing an improved process?

"I think we're going to see a shift in IT workers," he adds, "from writing functional specs and thinking about transactions to being process improvement specialists. They'll be operations-type folks who will help with workflows -- with IT providing the enabling technology."

David F. Carr is the Editor of Information Healthcare and a contributor on social business, as well as the author of Social Collaboration For Dummies. Follow him on Twitter @davidfcarr or Google+.

Though the online exchange of medical records is central to the government's Meaningful Use program, the effort to make such transactions routine has just begun. Also in the Barriers to Health Information Exchange issue of InformationWeek Healthcare: why cloud startups favor Direct Protocol as a simpler alternative to centralized HIEs. (Free registration required.)

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cbabcock
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cbabcock,
User Rank: Strategist
12/17/2013 | 1:48:58 PM
Avoid the Big Bank, which may be your system blowing up
Going step by step to implement the Epic system and isolating problems as you go is definitely the right approach. No one in their right mind would take a Big Bang approach and roll it out all at once.
David F. Carr
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David F. Carr,
User Rank: Author
12/17/2013 | 11:52:04 AM
Epic advice
If your hospital uses Epic, what's your advice for Partners about how to get the most out of it and achieve that goal of "clinical transformation" Noga talks about.
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