When University of Vermont Medical Center brought Adam Buckley on board in 2012, it was because they believed his focus wouldn’t be on what technology could do, but rather, how it could improve patient care. They were right. Two years later, he was named CIO of the medical center (and eventually the health network, when it was formed), and Buckley’s attention is still on how IS can be leveraged to provide better care.
In this interview, he talks about how being a rural organization affects his strategy, what it took to sell Epic to the board (and get through the state’s red tape), and his team’s plans for becoming an integrated system. Buckley also discusses the need to leverage the experience of others, why he refuses to believe that a CIO needs to be “a CISO and CTO rolled into one,” and what it was like to go from the hustle and bustle of NYC to cow country.
- UVHN’s 6-hospital, multi-state system
- Being a rural IDN: “It defines how we deliver care.”
- Certificates of Need for projects exceeding $3M
- “Vermont has its own unique flavor”
- Go-live planning — “Our goal is to do as much pre-planning as we can.”
- Eyeing Epic kick-off in Q1 2018
- Care access concerns — “Sometimes an additional 20 miles is a bridge too far.”
- Telehealth roadblocks
I came from NYC, which is a very different model. You have three other places down the street that provide care, and you never know where anyone’s going at any given time. They might go to one place for cancer care and another place for primary care. Here, people stay local. It’s a population that doesn’t have a lot of influx or efflux, and so it’s more stable.
It took us a while to put together the total cost of ownership, craft the Certificate of Need, and submit it to the state. There’s a statutory period in which they review it. There are questions and responses, there’s a financial and a project-based review, and there are testimonies. You contrast that with New York, which has an expedited IT review process.
These are massive projects with components that you don’t realize are going to take six months to define when you only have three months to do the work. And so we’ve taken advantage of the Certificate of Need process to really be planning to the Nth degree.
Some of our counties are not the wealthiest locations, and so there is a disproportionate impact when a service is lost. That’s an element we’ve kept in mind when we think about what services to offer where and drive toward delivering services as locally as possible, while maintaining the quality you need to make sure that you’re doing the right thing.
Gamble: Hi Adam, thanks so much for joining us today. Why don’t you start by providing some basic information about University of Vermont Health Network — what you have in terms of the number of hospitals, beds, things like that?
Buckley: Sure. The University of Vermont Health Network is currently a six-hospital network that exists across two states. It’s anchored by the academic medical center — University of Vermont Medical Center — and also includes two critical access hospitals, and three community hospitals. We’re split about 60/40 with the majority of beds located in New York. And although it’s not rare to have a health system that stretches across two states, it has been interesting with New York and Vermont having very different regulatory environments. That certainly adds to the complexity.
We are a rural integrated delivery system, and that also defines how we deliver care. We have an 850-person physician organization, and I’d say about 75 percent of our physicians are employed. We offer the full range of subspecialty services, and tertiary/quaternary care at the academic medical center, and we also have currently three skilled nursing facilities, and an accountable care organization that covers 60,000 lives.
We’re a $2 billion system at this point and we are continuing to expand, although I’d say the pace of expansion has plateaued somewhat. At one point we were onboarding people every six months as we brought on new hospitals, but right now we’re pretty stable in terms of size and footprint.
Gamble: And in terms of its history, the health system is only a few years old, correct?
Buckley: Yes. The first affiliation was between University of Vermont Medical Center and Central Vermont Medical Center, which had previously been affiliated with Dartmouth-Hitchcock Medical Center. And then Champlain Valley Physicians Hospital join us about five years ago, and quickly thereafter, we added Elizabethtown Community Hospital, Alice Hyde Medical Center, and Porter Medical Center.
Gamble: So certainly a lot of activity in just a few years. Do you feel like the organization has reached its capacity for the time being?
Buckley: I would say we’ve reached the boundaries of our natural catchment area and the natural referral patterns. There’s probably a little more expansion that could happen in upstate New York, but at this point, that’s nothing imminent. It really has more to do with where our patients are coming from and going to as opposed to other factors, and a lot of that is driven by geography and being a rural system.
I came from New York City, which is a very different model. You have three other places down the street that provide care, and you never know where anyone’s going at any given time. They might go to one place for cancer care and another place for primary care. Here, people stay local. It’s a population that doesn’t have a lot of influx or efflux, and so it’s more stable than other markets I’ve been in. And so from my perspective, where our patients come from has defined the boundaries of our network.
Gamble: Right. And along those lines, I read that UVHN had to file a Certificate of Need from the Green Mountain Care Board before launching the Epic EHR initiative. Can you talk about what that process has been like?
Buckley: Sure. Coming from New York, I’m certainly familiar with the Certificate of Need (CON) process, but Vermont has its own unique flavor to it. The Green Mountain Care Board is a governor-appointed board; they’re not legislators. They work on behalf of the state, and they review CONs for any capital outlay of more than $3 million. That’s an interesting dollar amount, because it can include everything from MRIs to routine equipment replacements and land acquisitions.
By statute, the University of Vermont Medical Center — and the Health Network, by extension — must submit a CON if they want to spend more than $3 million in capital. And so we made the decision four years ago now to start investigating what it would look like to be an enterprise Epic shop. At that point we still had separate systems for labs, PACS, radiology, scheduling, and revenue cycle, and we wanted to see what it would look like to become an integrated network.
Around this time, the network was coalescing into four core hospitals, and three out of those four required a CON. So we started looking at what the incremental expense would be to do Epic Connect and extend it out across the network. That’s where this project arose.
It took us a while to put together the total cost of ownership, craft the CON, and submit it to the state. There’s a statutory period in which they review it. There are questions and responses, there’s a financial and a project-based review, and there are testimonies. You contrast that with New York, which has an expedited IT review process. If it’s less than $150 million, you don’t have to do a CON application in New York. It’s just an application that would be reviewed briefly and most likely approved, because they’re dealing with projects in the hundreds of millions range.
So it’s a different process. It certainly extended the time frame from conception to kickoff, but one of the benefits is we were able to work with our implementation partners to frame a list of the key things people forget to do until the 90 days before a project kicks off. They gave us a list, and we’re working on that now. It’s given us an opportunity to think long and hard about aligning third-party built-on applications on the finance side, and do that work well in advance. We’ve aligned applications that are bolt-ons for clinical care that Epic does not provide. And so it’s given us an opportunity to plan out things that might get lost in the shuffle. These are massive projects with components that you don’t realize are going to take six months to define when you only have three months to do the work. And so we’ve taken advantage of the CON process to really be planning to the Nth degree.
Gamble: What are the next steps if this goes through?
Buckley: Our goal is to do as much pre-planning work as we can, which we’re allowed to do as long as we’re not spending capital. We’ve done as much pre-planning as possible. If we get approval this summer, we’ll decide how to manage the staff. As soon as we hire or move people into these positions, we’ll send them to Verona, Wisconsin to get trained with an approved CON.
Our plan is to formally kick off the project on Jan. 2, 2018, provided we have Green Mountain Care Board approval. If that drifts into the fall, that could push that start date back, but our goal is to do as much of the planning work in advance as we can. We have about a four-month window, which can’t be compressed any further, and that’s mainly because of the scheduling and travel involved with training. If we kick off Jan. 2, that gives us 18 months to get live on revenue cycle, clinical, and ancillary at UVM Medical Center, as well as Epic Ambulatory at all the health network ambulatory sites. Then we have a rolling big bang from there. The next stop would be Central Vermont Medical Center, which is a 100-bed community hospital, and Porter, a critical access hospital, both on the inpatient side. Last would be Champlain Valley Physicians Hospital, which is a 300-bed hospital in Plattsburgh. They’re last because they have a current vendor contract which doesn’t expire until 2019 for clinical and 2020 for revenue cycle. This way we can let the contract sunset naturally as opposed to having to pay a penalty for early exit.
Gamble: Okay. And University of Vermont Medical Center is the hub?
Buckley: Absolutely. It’s the only facility that offers tertiary care. We’re in the midst of deciding what type of specialty care is rendered where. We’ve already tackled the cardiovascular service line. For instance, open-heart only happens now in University of Vermont Medical Center but catheterization happens in Plattsburgh for the most part. So although University of Vermont Medical Center is the only one offering tertiary care, that’s not to say there aren’t specialty services at the other hospitals.
Over the past few years, we’ve been figuring out which services are ideal at which locations so that we can minimize patient travel. Because in a rural system without ample opportunity for public transportation, those distances are often at a disproportionate impact, and so we want to make sure our care is predicated on where the patients are who need those services.
Gamble: That goes back to what you touched on before with how being a rural IDN affects the delivery of care as well as your own strategy.
Buckley: Absolutely. We were discussing the loss of a dental clinic in the North Country of New York. Someone said, ‘well, they’ll only have to travel an additional 20 miles.’ But often, those additional 20 miles is a bridge too far. Do they have a car? Do they have money for gas? Do they have the ability to travel? Some of our counties are not the wealthiest locations, and so there is a disproportionate impact when a service is lost. That’s certainly an element we’ve kept in mind when we think about what services to offer where and drive toward delivering services as locally as possible, while maintaining the volume or quality you need to make sure that you’re doing the right thing at the end of the day. It’s a different challenge than you’d have in an urban or more hyper-competitive market, where often the things that you have to create strategies around are far different. So it really has been fascinating to be here.
The other element we are up against — and this is also one of the drivers for having a single EHR — is that we have been hampered entering the telehealth space, because we can’t make assumptions that patients have connectivity, even on a mobile device, because of the area. And so it informs our strategy pretty significantly what our patient population looks like, where they live, what kind of access they have, and what kind of means they have to achieve access, even if we were to provide it. All of those are pieces of the puzzle.