Healthcare is coming up on the 10 year anniversary of then President George W. Bush’s call to action – in his 2004 State of the Union address – to finally transform a paper-mired healthcare system into a digital-age industry that operates more like other sectors of the economy.

Coincidentally, this month Healthcare IT News is celebrating its own first decade. As we look back, we spoke to some leaders on the front lines of health information technology, asking them to take measure of how far they’ve moved towards a truly high-tech, data-driven system of care.

Bill Spooner, Sharp Healthcare

Bill Spooner, vice president and chief information officer of Sharp Healthcare in San Diego has had an epiphany or two on his way to digital transformation. There was a time, for instance, when he advocated for best-of-breed systems. But he changed his tune when he realized there were too many interoperability headaches.

In an interview with Healthcare IT News in early 2010, Spooner addressed the issue of best-of breed technology versus enterprise systems.

He was proud, he said, of his and his colleagues’ willingness to make a change when it became clear they needed to go in a different direction on their core hospital systems, or EMR, back in 2006.

“We were willing to recognize that the strategy we were taking in terms of our best-of-breed group of products just wasn’t going to bring us the value that we really needed to achieve,” Spooner said in the interview. “We began to pull out a half a dozen best-of-breed products in exchange for the integrated group of products that we are now implementing from Cerner.”

Spooner may have been early to change his tack, but today he is far from alone, with many medium and large health systems rolling out Epic or Cerner EHRs. Even pioneers in health IT are replacing their homegrown systems with commercial systems, usually with either Epic or Cerner, the two most selected enterprise EHR companies in the market today.

Partners HealthCare in Boston is in the midst of an Epic system rollout. Intermountain Healthcare in Salt Lake City recently announced a partnership with Cerner.

"We have very set ideas on how we think these systems should work, and we feel very passionately about it," said Intermountain CIO Marc Probst, in a video announcement last September. "Intermountain is committed to being innovative in the area of information systems."

Intermountain is recognized as one of the pioneers of innovation, having built its own systems from the get go to advance its data-driven approach to healthcare, which continues today.

Cerner’s open architecture technology was critical to Intermountain’s decision to partner with the EHR vendor, Probst said. Among other advantages, the open architecture will allow for the addition of the new Intermountain content. Cerner’s focus on population health was another attraction.

"We share a common vision to improve care for populations of people," said Brent James, MD, chief quality officer at Intermountain.

"This partnership will accelerate our efforts to provide core functionality to our caregivers as we create new innovations to transform healthcare,” he added, in a video announcing the launch. “By integrating the Cerner system with our electronic data warehouse, we will continue to drive improvements in healthcare quality."

At Partners HealthCare, Scott MacLean, deputy CIO and director of IS Operations, said: “We realized that much of the functionality we developed is available commercially, so we're adopting a vendor platform and will focus our innovation on genomics and other research discoveries we want to bring to the bedside and clinics.”

Sharp Healthcare’s Spooner said that today the health network has very little paper comprising the patient record. Physicians enter orders virtually, and they document online.

“The data has become actionable for care improvement,” he said.

In the not so distant past, physicians at Sharp Healthcare were not convinced the EMR was essential to the quality patient care, Spooner said. “Today they see it as indispensable to care. My challenge is to regularly bring added or improved EMR functionality, and to ensure constant availability – no scheduled or unscheduled downtime.”

Paul Tang, MD, Palo Alto Medical Foundation

As vice president and chief innovation and technology officer at the Palo Alto Medical Foundation, as well as a top federal policy adviser, Paul Tang, MD, brings a unique perspective, as does Probst who, like Tang, serves as CIO at Intermountain and also sits on the federal Health IT Policy Committee, which advises the federal government on healthcare IT matters.

The HITECH legislation, and the EHR Incentive Program in particular, was the most significant and impactful HIT federal policy in the past decade, Tang said. It was also a necessary enabler for the Affordable Care Act that followed a year later, he added, since health information technology and EHRs are essential to support the transformation required by health reform.

“It’s clear that providers – both physicians and hospitals – cannot undertake the transition from volume to value without knowing their current performance and its costs and without having an electronic infrastructure to effect continuous improvement,” Tang said. 

Tang is optimistic. He noted that in just two years time, the number of providers who have achieved meaningful use soared from about 3 percent, pre-HITECH, to more than 60 percent of eligible providers in 2013. Also, more than 80 percent of hospitals have invested in EHRs, he added.

“Yes, we have more work to do as we climb the meaningful use arc towards health information exchange, care coordination and patient engagement required in Stages 2 and 3,” Tang acknowledged. “But the laying down of an electronic infrastructure for the future is a salient milestone that wouldn’t have been possible without HITECH.”

John Halamka, MD, Beth Israel Deaconess Medical Center

John Halamka, CIO of Beth Israel Medical Center in Boston and a longtime standards guru, tends to focus his attention on the task ahead. But he has been thinking about the past recently.

“When I first became a CIO, my role involved writing applications and managing architecture at a detailed level,” he recalled.

However, over the past 17 years, he said, his role has become much more strategic. He’s had to make sure the right investments were made for BIDMC, that the right architecture was in place and that the resources were there to support it.

“I've had to master the political, communication and interpersonal skills of leading rather than the technical skills of being a strong individual IT contributor,” he said.

He’s had to do so, not merely as CIO of one organization, but also in his broader role in the industry. Halamka serves as chairman of the New England Healthcare Exchange Network and co-chair of the Health IT Standards Committee that advises the federal government. He is a full professor at Harvard Medical School, and a practicing emergency physician, not to mention that he and his wife Kathy are building Unity Farm, work that he chronicles regularly on his blog.
The work of the CIO and IT team has grown exponentially over the past 10 years, according to Halamka.

“BIDMC has grown by merger and acquisition requiring transformational IT solutions such as care management applications, population health analytics, community-wide HIE, big data management and mobile enablement for all our stakeholders,” he said.

BIDMC is not unique in finding itself in this position, and some can’t keep up.

“Demand and expectations have exceeded the ability of many IT organizations to keep customers satisfied,” Halamka said.

Scott MacLean, Partners HealthCare

Scott MacLean, deputy CIO and director of IS Operations, at Partners HealthCare in Boston, said he and his colleagues approach their work differently today than 10 years ago.

“We are not arguing that CPOE, electronic medication administration and other EHR functions are efficacious,” he said. “We are busy optimizing and measuring the results of these interventions.”

Just as CIOs and IT teams have changed how they look at their work, so have organizations. At Partners, which is in the midst of an Epic system rollout, MacLean says: “We realized that much of the functionality we developed is available commercially, so we're adopting a vendor platform and will focus our innovation on genomics and other research discoveries we want to bring to the bedside and clinics.”

As he sees it, collaboration has taken hold across the industry, and interoperability is top of mind.

“In the past, healthcare systems sought to keep their patients' information and HIT vendors wanted to sell all of their products to a provider, MacLean said. While that may still be the case at times, he said, “policy and payment models are driving collaboration, which will benefit consumers and save money.”

Collaboration is on Ed Ricks’ mind, too. Ricks, vice president and CIO at Beaufort Memorial Hospital in Beaufort, S.C., said, “I think it's a very different skillset today. We're collaborators now, working with the medical staff, and I'm trying to make the technology invisible to clinicians, and to open workflows. The technology is so cool right now and nobody has to care about the tech as much as what it does."
 
George Hickman, Albany Medical Center

George Hickman, executive vice president and CIO at Albany Medical Center in New York State’s capital city, works as hard as he ever has over the past 10 years, but he has to be more strategic, he said.

“I move as fast as I ever did,” Hickman said, “but I am much more deliberate about priorities. I pay attention to what could be most beneficial, most costly and most risky – in both qualitative and quantitative terms.” This change, he said, is both intuitive and analytical, and it has come with experience.

As was the case with many other health systems across the country over the past 10 years, the biggest change at Albany Medical Center was the implementation of an enterprise-wide electronic health record system, Hickman said, and all the supporting, secure infrastructure and people change expectations.

Hickman foresees many more challenges ahead. “How we understand, use and even exploit our data will be our next ‘EHR-like’ challenge,” he proffered. “I expect that this frontier will take the same sort of time and teaching patience, may be somewhat costly, and will certainly be transformative.”

Harry Greenspun, MD, DeLoitte

"When you think back 10 years, at that time we had an industry way behind others," said Harry Greenspun, MD, senior advisor at Deloitte's Center for Health Solutions. "Stimulus and meaningful use gave us that push. It has created a tipping point of EHR adoption, now it's actually happening and not just among brave innovators but bread-and-butter folks."

As Greenspun sees it, pretty soon, if you can't do a lot of simple things, like checking in at the doctor's office electronically, it will be hard to remain competitive.
"My needs as a patient haven't changed, but my expectations as a consumer have," Greenspun said.

Geeta Nayyar, MD, PatientPoint

Call her a poster child for the health IT generation. When Geeta Nayyar, MD, chief medical information officer at PatientPoint, graduated from medical school in 2003, one of the things she looked for in a residency program was that the hospital had some sort of electronic medical record. 

"Everything was paper-based – charts, labs, X-rays," she recalled. She did not want to spend her time prowling around the bowels of a hospital to find patient information, she said.

By the time she started her fellowship, that hospital had a fully integrated EMR.

"We have this whole different ball game today where the EMR is basic and a lot of the graduating students don't use paper charts," Nayyar said. "In 10 years, we have come a very long way. It's not just the infrastructure being laid. Even more important, it's the application."  

What do you wish had gone differently?

CIOs don’t tend to be a coulda-woulda-shoulda bunch, but they don’t mind engaging in a little Monday-morning quarterbacking now and then. So, what might have gone better in the past 10 years to nudge U.S. healthcare to an even better place on the digital continuum?

“I wish we had made greater progress towards standardization – vocabularies, care practice, etcetera  – and interoperability,” Spooner said. “I wish EMR products had opened to interoperability much farther than has been the case.”

For Halamka, it was without a doubt, “certification and overall program timing.”

“Part of the problem, as I've discussed previously, is that the certification criteria are overly burdensome and in many circumstances disconnected from the attestation criteria, requiring very prescriptive features that go beyond the intent of Policy Committee and Standards Committee,” he wrote in a Nov. 27, 2013, blog post, titled “Rethinking Certification.”

In that blog, Halamka discusses the benefits of “agile technology” over “waterfall technology,” which was the method used to derive the regulatory language and certification scripts.

“I've spoken with many EHR vendors (to remain unnamed) and all have told me that they created software that will never be used by any clinician but was necessary to check the boxes of certification scripts that make no sense in real world workflows,” he wrote.

In a November 20, 2013, blog post on fine-tuning the healthcare IT timeline, he wrote: “People are working hard. Priority setting is appropriate. Funding is available. The problem is that the scope is too big and the timeline is too short.”

On Dec. 6, 2013, CMS and ONC announced an extension to the meaningful use program.

“Under the revised schedule, Stage 2 would be extended through 2016 and Stage 3 would begin in 2017 for those providers that have completed at least two years in Stage 2,” acting national coordinator Jacob Reider, MD, and Rod Tagalicod, director of the CMS office of health standards and services, announced.
MacLean is on board with all the changes that have been required to move healthcare from a paper-based system to a digital one. But he wishes it could have been accomplished differently.

“I wish the industry could have reformed itself without government intervention and public spending,” he said. “I think it's unfortunate that the myriad regulations stifle innovation in clinical care and payment models.  Still, we have tipped the fulcrum on HIT adoption and I don't think we'll be going back.”

Hickman, at Albany Medical Center, said he wishes “we knew when to understand that something didn’t need to be invented here. We could have done more, and faster.”

Looking to the future

Glen Tullman, former Allscripts CEO, turned venture capitalist and – as reported in Crain’s Chicago Business – creator of Ignite Glass Studios, a 20,000-square-foot, $5 million glassblowing facility he built in Chicago, continues to be bullish on healthcare IT.

"In the last 10 years, electronic health records have laid the foundation for everything that will change health and healthcare going forward,” he said, “just as computers paved the way for the apps that changed how we do almost everything in the rest of our lives. We’re closer than ever to enabling the intelligent, connected health consumer and, as in other industries, consumers equipped with information, mobility, transparency and access will change everything.”
He recognizes that many challenges remain, but he remains optimistic.

“As for those who point out what’s not working, those are just opportunities for health IT leaders to solve,” he said. “I believe we’re closer than ever to improved outcomes and bending the cost curve in the right direction.”

Spooner envisions a future – perhaps in 10 years – of smooth interoperability.

“Patient information will be interoperable across EMR systems, he said. As he sees it, the patient will be able to transport his full record from provider to provider irrespective of EMR choice. The patient will own the record and will enter/edit his own data to the EMR. 

Also, “the U.S. will adopt a uniform patient identifier,” he added.

Compared to 10 years ago, Tang says, “I am more confident that the country will make the necessary paradigm shift from fee-for-service transactional care delivery to one focused on community health and wellbeing now that we are building the necessary information tools to support that transformation. 

Denni McColm, CIO at Citizens Memorial Healthcare in Bolivar, Mo., recalls that it was 10 years ago – in December 2003 – that Citizens Memorial eliminated paper medical records.

“At the time, we thought everyone was doing the same thing, but found out over time that others were still just talking about it,” she said. “I'm surprised by how many hospitals still have paper medical records now. I'm thankful we were naïve enough not to know any better back then.”

Mulling it over today, she said, “It did teach us that following what everyone else is doing in IT is not always the best approach.”

Citizens Memorial Healthcare, a 76-bed fully integrated healthcare system, has never let its small size stand in the way of progress. In 2005, it was awarded the prestigious Davies Award from HIMSS, and in 2010, the health system reached Stage 7, the top level, on the HIMSS Analytics EMR Adoption Model scale.
MacLean’s high hope for the next 10 years of healthcare IT is that “we as consumer/patients will engage with the system and hold providers and payers accountable for quality and service.”

As for Halamka, he likens healthcare IT progress to air travel.

“When I became CIO in 1998, it was the Wright Brothers era of healthcare IT – building new technology was an amazing accomplishment,” Halamka said. “Today we're in the biplane stage – solutions are commercially available but they are not agile or usable. I look forward to the Airbus 380 stage when the technology is safe, convenient, reliable and well engineered for purpose.”

Tang apparently prefers the train analogy.

“The journey, and work, is far from over,” he said, “but with the progress the country has achieved, the train is well out of the station, and we are well on our way towards a more adaptable and rational health system.”