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Part 2: Musings from the Burn Unit

by Todd Rothenhaus, MD, Chief Medical Officer

You may recall from Part 1 of the Burn Unit series, I began sharing some experiences with deploying ambulatory EHR at Steward Health Care. My first realization was that the traditional software model (on-premises hosting of application servers and systems) didn’t really fit the ambulatory model. Given the high pace of change in health care IT, Meaningful Use, ICD-10, 5010, and everything else, the need for frequent updates are as important as ever. Having to take new code meant having to pull resources off other projects, and EHR was taking a whole lot of resources to begin with.

An even bigger issue was having to own the entire application. Every time we rolled out a new practice, we repeated the same exact steps: spin up a VM, have the vendor deliver the code, configure the system, prepare content, enroll providers in electronic prescribing, test and deploy interfaces, etc. Every time we encountered a configuration issue, we owned it. If we found out a pharmacy had changed their fax number, we’d change it ourselves–in our nearly seventy separate practice databases.

We were less than 25% through our 1,500 affiliates, most of whom were 1-3 doctor practices, and new agreements were coming in weekly. It just wouldn’t scale. I realized: even an ASP model won’t help.

As CIO, I saw a lot of web-native stuff that looked pretty good to me–-no CAPEX investment, subscription model, automatic updates. The only problem was that these offerings were not really connected to our outcomes–-and many of them cost a lot. It seemed that a lot of vendors were using the web to cut costs, but were pocketing the entire difference without offering any additional value. At one point I was presented with a $700,000 subscription for order sets!

While were we painstakingly figuring out how to build individual data capture elements into our legacy EHR, athenahealth’s Clinical Intelligence team took our managed care contracts and pre-configured athenaNet to capture every P4P measure our physicians were enrolled in–-customized by patient and by contract. Then they did the same thing for Meaningful Use. At that point it dawned on me: the same company that wrote the code should provide expertise and service to configure it, and be at risk for outcomes.

As we continue to collectively force-feed IT to into the health care economy, health IT strategy must evolve from “roll out EHR” (which everyone is doing) to include new approaches to electronic patient relationship management, advanced integration, and data analysis across the continuum of care. For IPAs and POs without hospital affiliation, the commitments in cash and time to develop an “ambulatory strategy” are overwhelming. For hospitals and health systems, there are too many projects getting in the way of real innovation.

As a CIO, I welcomed the opportunity to take some of the ambulatory work off my plate.

Rothenhaus is the chief medical information officer for athenahealth.

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