Delivery of Care

Entering the brave new world of health IT

An interview with Care New England’s Dennis Keefe on the installation of EPIC on how it will transform the delivery of health care in Rhode Island

PHOTO BY Rupert Whiteley

Care New England President and CEO Dennis Keefe talks about the installation of the Epic health IT system and how its tools will move the hospital system away from fee-for-service.

By Richard Asinof
Posted 9/1/14
The first installation of Epic in Care New England’s ambulatory care settings marks the move away from fee-for-service toward global payments, population health and the transition toward patient-centric and patient-directed primary health care. Within two to three years, about 80 percent of Rhode Island’s health care delivery will be measured and quantified through the Epic health IT platform. Dennis Keefe, president and CEO of Care New England, provides the context of what those changes will mean in a conversation with ConvergenceRI.
How will the cost containment tools be integrated into the statewide health care planning moving forward? What will be the opportunity for neighborhood health stations to grow up as a community force within the new health IT framework? How can the nimbleness and flexibility of innovative approaches at the clinical care level be encouraged? How will the dynamics of the changing conversation between caregivers and patients be reflected in the new Epic platform? What role will the state play in leveraging the importance of interoperability of all systems?
The political arguments that divide the country over the implementation of the Affordable Care Act, or Obamacare, here in Rhode Island and across the nation, are a distraction from the large economic issues that confront the state in health care delivery. Health care has been avoided by the candidates – and the news media – in the 2014 election campaign; there has not been any constructive policy debate about the critical choices facing Rhode Island. No matter that the health care industry sector is the largest private employer in Rhode Island, or that the health care reform evolution “train” has already left the station.

PROVIDENCE – Did you feel the Earth move under your feet? The world of health care delivery in Rhode Island has begun a tectonic shift toward population health management, global payments and shared savings, with the beginning of a phased-in installation of Epic’s health IT platform, beginning with the ambulatory practices within the Care New England’s system.

The first two practices are now live – with the plan to install the Epic platform in all the Care New England ambulatory areas – physicians employed or who have professional service agreements or who are affiliated with Rhode Island’s second largest hospital system.

Over the next two years, the phased-in deployment will continue, with ERs first and then in-patient hospital systems, in Care New England’s $50 million investment in health IT.

Within two to three years, as a direct result of the new Epic health IT platform, Care New England will have more than 50 percent of its financial reimbursements flowing from bundled and global payments instead of fee-for-service, Dennis Keefe, president and CEO of Care New England, told ConvergenceRI in a recent interview.

Care New England is not alone; next year on March 29, Lifespan is scheduled to go live with its new $100 million Epic health IT platform across all of its system, according to physicians. All of Lifespan’s employees are scheduled to have at least 20 hours of training in advance of the system going live, according to a number of Lifespan employees.

The two largest hospital systems will soon be joined by CVS Caremark, which is also planning to adopt Epic’s health IT platform as its operating system, though the retail pharmacy behemoth did not release a price tag on the investment.

Together, with three of the largest health care systems operating in Rhode Island having the same health IT platform, covering as much as 75-80 percent of Rhode Island’s population, the dream of a common language with built-in interoperability seems a tangible outcome – if the competitors can forge inclusive, working partnerships around shared data, and if they don’t engage in market power behavior toward those non-Epic systems.

ConvergenceRI sat down with Keefe on Aug. 25 to talk at length about these changes in health IT mean for the delivery of health care, cost containment, improved health outcomes and connectivity.

Keefe, who often invokes the phrase, “The market waits for no one,” also ended by the conversation by suggesting that there needed to be a redistribution of resources at the front end of the system, in terms of better prevention and health promotion.

“The way that the American health care system has been built, all the resources have gone to the back end. As we go forward, with population health management, I think there’s more than enough money in the health care system to create a healthier population across the board.”

To do that, Keefe continued, “We need to reinvest in the front part of the health care system and be more effective in the back part of the health care system, to change the flow of those dollars from the back end to the front end.”

ConvergenceRI: How is the installation of the new Epic health IT platform going?
KEEFE:
Let me back up a bit. I’ve been in the business for over 40 years. Like a lot of health care executives, I’ve been tremendously disappointed by the ongoing return on very significant IT investments in actually improving health outcomes, in improving efficiencies, and really getting to the promise of what IT could and should do, that’s been done in a lot of industries but not so much in health care.

Epic has the ability to leverage IT to do just that, to improve health care, to improve outcomes, to improve performance, to improve efficiencies.

It’s second to no IT system I’ve seen, in my career.

That doesn’t mean there aren’t other good systems out there. But if you look across the country now, Epic is literally winning three out of every four proposals of systems that are thinking about going in a new direction for IT.

Some of the real winning organizations, like Kaiser, like Geisinger, like the Cleveland Clinic, like Partners, everyone’s going to Epic.

There must be something more to it than being just another IT system. I think it relates to health care delivery reform, payment reform. Which platform best supports the future that we’ve all entered.

My experience – [in my work in Cambridge, Mass.] we were one of the early adopters of Epic back in 2002. By the time I left [four years ago], we had really started to leverage some of the ways that the system could do to improve care.

There are a lot of ways you can implement a new IT system. I’m not here to suggest that one is superior to the other. They all have pros and cons.

One is the so-called big bang implementation. I believe, and you can verify this with Tim [Babineau, president and CEO of Lifespan], that’s what Lifespan is doing. I believe the date set is April.

That’s one approach, switching over from one system to another system, literally overnight. There are various backup systems in place to make sure that things don’t totally crash and burn.

Or, you can take a more phased approach; at Care New England, we’re doing more of a phased approach.

We’re focusing first on the ambulatory care areas – where we have relations with physicians, where physicians are employed by us or have professional service agreements with us, or have an affiliation agreement with us.

We are seeking ways to connect all of those providers into the Epic ambulatory system.

ConvergenceRI: If the physicians have a different health IT system, is there interoperability with the new Epic platform?
KEEFE:
Interoperability has come a long, long way. So, the answer is that, our preference is, if they are willing, we convert them to Epic.

Epic has a module they call community connect, a suite to support physicians in their offices, while at the same time, allowing two-way communication that’s needed with an electronic health record.

Certainly, our employed physicians would get it as part of being employed here, and our contract physicians would get it if they so desired.

ConvergenceRI: And, if they didn’t desire it?
KEEFE:
Then you can be interfaced. Epic has really spent enormous sums of money improving their interoperability ensuring the interfaces that are necessary can be done.

So, where the willingness to be interoperable was an issue three to five years ago, Epic has really understood the new needs of health care, and what kind of functionality you need in an electronic health record.

We have seen that Epic will work with us to overcome any barrier, to really get to this idea of an electronic health record.

ConvergenceRI: Interoperability has been a problem with other health IT systems, and not being able to talk with other systems.
KEEFE:
It’s going to be an interesting challenge for such companies. If you just look at Lifespan and Care New England, with us both going full Epic over time, we will cover 75 to 80 percent of all Rhode Islanders seeking health care. That’s very significant. It’s also good that CVS is going to Epic.

ConvergenceRI: With three of Rhode Island’s largest corporations all going to Epic, will it create a problem, similar to what happened with Microsoft and the way it parlayed its market power – despite the fact that other systems, such as Apple, were more intuitive and graceful?
KEEFE:
Critics always bring up the fact that Epic is getting too big or too dominant, asking if Epic will continue to adapt to the ongoing technology and changes that everybody is going to continue to experience.

What I can tell you is that Judith Faulkner, [the founder and CEO of Epic], and I know her personally, is a true visionary.

I think that as long as Judith is at the helm of Epic, a lot of concerns that are out there are not going to be realized. She really takes her responsibility as an owner of this huge enterprise very, very seriously. And there’s no hint that she’s willing to sell or step away any time soon.

As long as Judith is at the helm, they are investing very, very heavily in the future development of Epic in the way that it supports health care reform and payment reform and big data, because it’s becoming a big data world.

They’ve invested millions and millions of dollars in being able to manage big data and bring forth information that is critically important to payment reform and managing population health, actuarial information we’re going to need to be successful as we move forward.

ConvergenceRI: And in terms of mobile apps?
KEEFE:
I’m sure you’ve heard about their joint venture with Apple. It’s evidence that they don’t have their head in the sand in terms of what the future might look like, that shows me that they understand that they actually need to make that part of the business better. Who better to partner with than Apple if you want to get into apps?

ConvergenceRI: In terms of health care facilities that have successfully been able to integrate health care IT at the point of care, such as Blackstone Valley Community Health Care, will they be able to become interoperable with the Epic system at Care New England?
KEEFE:
They do a really good job out there. It’s an outstanding example. With their NextGen system, they’ve gotten a lot of leverage, they’re very proud of it, and it works for them. Unless they came to us and said we need to be Epic, we would be looking more to interface with them.

ConvergenceRI: And that wouldn’t be a problem?
KEEFE:
I don’t want to misspeak. We certainly would strongly support an interface. We certainly would advocate with Epic for an interface. There may already be an interface that I’m not aware of. But that would be the goal, connectivity.

The goal is to get everyone connected. I don’t see it as a competitive issue. If it improves patient care, I’m going to support it. We have to set aside our differences and share information.

If you don’t have collaboration, partnering and sharing in your corporate DNA, it makes it very difficult to get to where we all need to end up.

ConvergenceRI: How did the installation go with the first two ambulatory practices?
KEEFE:
We had two practices, and the way this works, that with the first two practices, there are going to be issues, because you’re going to learn things. …There’s going to be a lot of learning.

For instance, with the first two practices, there were some problems, between about 150 and 200 issues. That is why we need people at the elbow once you turn the switch. But, literally, with 24-48 hours, 90 percent of those issues had been dealt with.

What happens when you do a phased-in roll out, for the next wave, we know some of the issues, it shortens the learning curve. So that with new wave, as you do this, you get smarter and smarter. It shortens the cycle of effective implementation.

The beauty of doing all this [first with the ambulatory care] is that Epic was first built as an ambulatory system. It’s really where they’ve built their competitive edge. That’s why our focus is on ambulatory care, first and foremost.

Because if you look at health care reform and payment reform, it’s really about patient-centered medical homes, it’s about ambulatory care, it’s about the electronic health record supporting strong ambulatory care across the system. That’s the most important part of the overall implementation.

We have a new chief information officer, she literally started two weeks ago. I want her to get a chance to assess the environment, to assess how we’re going to move forward. She’s done both [kinds of installations], a big bang and a phased installation. The goal over time will be to complete the ambulatory rollout, then complete the rollout to our ERs, and then inpatient.

ConvergenceRI: Is there an equation of how the $50 million cost will be leveraged in terms of health outcomes and return on investment?
KEEFE:
We’re an aircraft in flight. I would suggest that we’re only two or three years from being paid greater than 50 percent of our payments from some kind of a global capitation system or a payment system that significantly moves us away from fee for service.

Those changes are happening, they are dynamic. The only way that you can succeed and thrive in that environment is to have a very sophisticated electronic health record – and the population health management tools are going to be necessary to support us in the area of payment and delivery reform.

We’re definitely moving in that direction – two to three years to be fully deployed to be ready for the new world of payment reform.

As we go in that direction, what we are trying to do is build in protections along the way, with Medicare shared savings and the Medicare ACO, where you can minimize your downside risk.

In the early years, as we’re getting all this deployed, and we’re developing our competence with care coordination, that’s how we’re able to stay financially within our overall budget as we move in that direction.

It’s the same thing in our discussions with Blue Cross [& Blue Shield of Rhode Island], our major payer. Part of the discussion is to create this glide path as we go forward.

Because you can’t turn the switch, as you know, and go from one system to another. You really have to have time and financial relationships that allow you, over time, a glide path.

Also, very important, in Rhode Island, you [want to make sure] that you’re not impacting the job market in a way that would be detrimental to the Rhode Island economy.

I think, at the end of the day, there won’t be an incredible change in the number of jobs in the Rhode Island, but there will be a lot of retraining and new skills are going to be needed from the workforce that’s going to be required under payment reform and delivery reform.

All of this needs to happen in a very organized way, with stakeholders working with us as we transition form where we’ve been, where we are, and where we need to go.

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